Janice, a forty-four-year-old full-time schoolteacher, visited her doctor’s office complaining of fatigue, difficulty keeping up with the demands of her busy family of three children, lack of interest in sex with her husband, and irritable outbursts that were getting her into trouble at work and at home. ‘Up until six months ago I was feeling all right, particularly during the summer holidays’, she said. ‘But things went downhill, and by February, I knew I needed help. I can’t even sleep well. I keep waking up at four or five in the morning with a sick feeling in the pit of my stomach, as if I’ve done something terribly wrong.’
Janice’s doctor asked if anything had happened six months ago. Janice couldn’t recall anything very significant. She did remember being upset in June because of education cutbacks that meant she would have to work longer hours in a job that bored her. With her husband’s business not doing as well as they had hoped, she couldn’t afford to decrease her hours, and she admitted to being somewhat resentful about it.
Finally, though, something else came out. Janice said that her estranged father, who had left the family when she was eight because her mother could no longer tolerate his drinking, had come back into her life and was terminally ill. She remembered him being playful and fun when she was a little girl. He had always seemed to adore her, but she had seen very little of him after the breakup, and he had not helped with her expenses or schooling. Janice had had problems in her last year of university and had spent long periods in bed that winter, missing so many classes that she had almost failed. She had gone to the student health service but had been too embarrassed to talk about her problems.
Janice looked sad. Her eyes teared as she spoke, although she didn’t cry, and she seemed restless and uncomfortable. She had no makeup on, her hair was unwashed, and there was a stain on her blouse. The doctor was concerned about her dishevelled appearance and her obvious unhappiness.
Janice’s doctor began by getting as thorough a history as possible. The doctor let Janice tell her story in her own words, and went on to ask her when she had started feeling bad, what events such as life changes or illnesses had been going on at the time, if there were any medical illnesses or drug therapies that might coincide with the onset of her feeling low. How incapacitated had she become? Was she eating and sleeping? Was she able to get up and dressed in the morning? Was she still able to work? Did she still enjoy her regular activities in the evening? What had she tried to do so far to make herself feel better? And, most important, did she feel so bad that she’d lost hope and thought of killing herself?
The doctor also inquired about other bouts of psychiatric illness, and any allied symptoms, such as panic attacks or obsessive-compulsive symptoms. ‘Do you have a feeling as if something terrible is going to happen, and you break out in perspiration, and your heart starts beating fast? Do you find you can’t leave the house without checking the cooker and the door over and over, or do you start to badger yourself about saying the wrong thing or not doing something you should have, and you can’t let it go?’ The doctor asked about physical ailments such as headache, chest pain, stomach pain, or excessive drinking. ‘What sort of person were you before you became sick – were you outgoing and sociable or quiet and retiring?’
Then Janice’s doctor looked for illness in the family. Had any relatives related by blood – such as mother, father, grandparents, aunts and uncles, brothers, sisters, children, nieces and nephews – been treated or hospitalized for depression or anxiety? Were there hints of suicides and alcoholism? In many families, these illnesses are kept secret out of embarrassment. The doctor also checked for less obvious symptoms. Were Janice’s parents moody, outgoing, crotchety, withdrawn? Were they able to form relationships, hold down jobs, participate in the community? These are all signs of healthy functioning. The doctor asked about early losses, chronic illnesses, and neglect by her parents in childhood. Eventually, based on all this information and more, Janice was diagnosed as having a major depressive episode – a common and serious form of depression.
This may seem like a lot of information to ask someone who doesn’t feel like talking, but people can be amazingly open when they first come for help. In many cases, the first session produces all the information the doctor needs for the rest of the therapy. The facts learned later are like commentary on the first session.
A good medical and physical examination is done to rule out any contributing medical illnesses. Ideally, the physical examination should be done by a doctor who won’t be counseling the person. There might be valid reasons for this. Many depressed people have had unpleasant and physically intrusive experiences with caregivers in the past, and the examination may feel invasive and uncomfortable. This option of different doctors is often not available, so the family doctor may do both the physical examination and the psychotherapy.
