Sunday, September 29, 2013

A Simple Case of Depression

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

It started off as a seemingly straight-forward case, as it often does. The patient ("Kevin") was a shy, quiet 13 year-old young man, one who had "never caused any trouble," according to his parents. Until earlier this year, he had gotten straight A's, enjoyed reading, and regularly hung out with several friends. Then, during the second semester of the previous school year, he just stopped doing his homework. He also started spending more time on the computer and less time with friends. His grades dropped to C's and D's, and two weeks into this school year, he was still not doing his homework, which is what prompted the evaluation.

Talking with Kevin, his face was a blank mask. He did not feel sad or depressed, but he no longer enjoyed reading or felt motivated to do homework like he used to. He spent all his time on Facebook or playing computer games. He stayed up late and woke up early, felt tired all the time and had trouble concentrating at school. He occasionally had thoughts of not wanting to live, though he has never seriously contemplated suicide or harmed himself. He was also eating less than usual, and often had negative thoughts about himself, that he was a failure.

He clearly met the criteria for a major depressive episode, and if I were using a purely biomedical approach to psychiatry, I might have been satisfied with starting him on a serotonin reuptake inhibitor and hoping that he will be feeling better in about a month. However, his seemingly out-of-the-blue changes in mood and behavior struck me as odd. I was also struck by the fact that he was only now being evaluated, even though his grades started dropping over 6 months ago.

During the initial visits, Kevin's parents had insisted that there was no family history of any mental illness or substance abuse. They had a close relationship with their son, and they frequently went to the movies or baseball games as a family. However, the more I talked to Kevin, the more I learned about the nuances of his family. His parents were widely inconsistent in how they approached his struggles. His mother yelled at him when he got bad grades and told him he could not use the computer, while his father was more lenient, did not set limits, and even bought him an iPad after his grades started slipping. When one parent's approach did not seem to work, the other parent took over for a while, until that approach failed as well.

I spent a good deal of time talking with Kevin's parents about the importance of them both agreeing on their parenting approach, so they can set reasonable limits around electronics use and enforce bedtimes that allow Kevin to get adequate sleep. After a couple of weeks, Kevin's sleep improved, and he felt less tired during the day, but he still was not doing his homework. I continued to talk with Kevin about his family life, having him walk me through what happened in the evenings. The picture that emerged was not that of a close-knit family. Over the last few years, the family had stopped eating together at the dinner table since Kevin's father had been getting home later from work. After work, both parents tended to unwind by drinking. Their jobs have gotten more stressful in the past year, and Kevin told me that they have been drinking more as a result, at least 3 to 4 drinks per parent per night. He was essentially left to his own devices while his parents enjoyed their beverages.

I have no way of proving this, but I thought it was a strong possibility that Kevin's refusal to do homework was an attempt to get his parents to notice him and reengage with him. When I brought up the issue of alcohol with Kevin's parents, they both seemed surprised that he was aware of their drinking habits. They told me that they were doing most of their drinking when Kevin was already asleep, which really made me wonder just how much they were drinking. I did not tell them outright to stop drinking, but I asked them to think about if and how their drinking may be impacting Kevin.

After that, I never heard from them again. Perhaps I came across as judgmental, or perhaps I tried to push for too much change before I had established enough rapport with the family. But it was clear to me that Kevin's "depression" could not really improve without some serious behavior change from his parents. Sometimes I think about the appeal of simply focusing on the identified patient and what brain chemicals may be awry. But then I remind myself that complexity is what drew me to psychiatry in the first place. With a more comprehensive approach, at least I sometimes feel that I get a peek behind the curtain at what's really happening, even if I am often unable to do more to influence the outcome.