Saturday, March 4, 2017
Making of a Child Psychiatrist: (58) The General Practitioner (3)
There is a social side to living in a small community. Part of that is an expectation perhaps that the doctors would be colleagues and friends even if they were not best buddies. Certainly I felt fairly close to John Hayden even if he had the odd funny idea like it being OK to threaten violence to fathers who abused their children! Early in our being part of the practice, he and Barbara invited us round for Sunday afternoon tea. It was only a short walk from our house to theirs, but with Rod only being a few months old, and Jonathan not much more than two, we took the car round the long way to Shakespeare Road. Jonathan had not been all that well, but we did not think much of it until he was more than usually shy, not keen to play Barbara’s children, and apparently not hungry. John must have given him the doctor’s quick appraisal, because he asked: “Has he had the rash very long?” To which we replied: “What rash?” Very embarrassing really, but when we looked at the poor little mite, he did have rather red cheeks, and when I felt his forehead he did have a slight temperature. John laughed, and Barbara, a nurse, said: “Well it does look a bit like Measles, but both of ours have had that, so not to worry.”
Not the most auspicious start to a friendship of families, and it showed that while I might have been very highly trained in medicine and managed to gain the prize in medicine for my cohort at King’s, but common things were common in general practice and I had had so little experience in common things that clearly I had a long way to go. I had never seen a case of measles; I vowed never to miss another. We recovered slowly, but I always felt I had rather a lot to prove.
I was on safer ground with depression, and was curious about how many cases I might find in my day-to-day work. In retrospect, what was different about the cases I saw was that the primary reason for coming to see me was to improve matters. I can only barely remember writing certificates for time off from work. There were the usual background reasons to mild depression – the loss of a relationship in the late teens or early twenties, a loss through death of a loved one (including loss of child in an early pregnancy), and occasionally an episode of bullying at work, or a public shaming for some misdemeanour. There were certainly a range of ‘interesting’ people in our community, but I cannot remember seeing many cases that I would be prepared to call a personality disorder (with or without depression). I did know of a couple of people who had spent some weeks in St Augustine’s, our local psychiatric hospital near Canterbury, but oddly they were through social contacts rather than patients of the practice.
Another oddity was that very few of the over 3000 patients in my practice had been medicated for a mental illness, and it was only very rarely that any of my colleagues took the option of discussing a patient with a mental health problem. So was this something to do with the type of community – semi-rural and seasonal holiday oriented? Was it to do with the slower pace of the times, or perhaps fewer personal life expectations, or perhaps to do with the sense of community support that existed? Or perhaps it was due to almost full employment for those that sought it, even if some of it was seasonal. Or was it perhaps related to stigma; that is you stoically managed your own mental health, and would have been very embarrassed to admit that there was a ‘mental problem’.
I was, as you may imagine, on the lookout with a slightly higher alertness. Strangely, the patients who did come to see me came for physical symptoms. There were several people who complained of tiredness, sluggish thinking, weight gain and mild depression, who clearly had early myxoedema and, after relevant tests and a visit to a local physician, responded very well to treatment with Thyroxine.
Conversely there were several people who complained of a racing heart or dizziness, or excessive perspiration. After we excluded and/or treated a thyroid problem, there were a few left who had clear cut generalised anxiety, came from an anxious family, and responded to fairly simple explanations, some desensitization procedures I had learned, or a very short course of diazepam to help them through a time of change.
There were a small group of people, more men than women, who complained of tiredness and poor functioning at work accompanied by occasional dizziness, or recurrent and sometimes very severe headaches. Many used the word ‘depressed’, but a physical examination revealed a very high blood pressure. This, once treated with an antihypertensive seemed to sort matters out. Occasionally I managed to get them to lose a small amount of weight, and increase their exercise load through walks along the sea wall. And this, too, seemed to contain the problem. The modern penchant for competing marathons had not been invented. Nobody seemed to need the gymnasium-based frenzy of various forms of exercise that we now see touted, and the one or two gyms in Thanet seemed to be limited to boxers.
With those where there was no other cause for their depression, I was perfectly comfortable to prescribe either of two tricyclic antidepressants, and take them through the course and see them improve.
There was one spectacular case. I was asked to do a house call on a young woman who had recently given birth to a healthy son. The midwife and family members were anxious that she seemed in despair, seemed to be losing her interest in her new baby, and spent all her time in bed sleeping or weeping. Her husband complained that she had become totally different and he was ‘unable to reach her’. Her mother had moved into the house to ensure the physical care of her daughter, and her new grandson. But she was beginning to feel worn out.
My clinical history suggested a severe postnatal depression, and I thought she should be in a safe hospital environment. This suggestion was rejected with anger and threats of self-harm, and my patient (and her mother) begged me to treat her at home. I was anxious. Clearly she needed to have a rapid response to treatment, and I wondered how we would be able to manage. At home I did some reading, and then took the step of phoning one of my senior colleagues at King’s who had been involved in the trial of intravenous clomipramine when I was a registrar. He remained enthusiastic, quoted his recent apparently excellent research results about the speed of recovery, but did acknowledge that he had not heard of clomipramine use in postnatal depression. He encouraged me to ‘give it a go’.
I spoke to the local chemist, and he found out from the pharmaceutical company he could gain access to a 10-day course of clomipramine in liquid form for intravenous use as part of a slow infusion of a daily saline drip. I completed a further physical of my patient, which included an ECG using our new portable machine. I explained the whole process carefully to my patient and the family, including any possible side effects. Excited and nervous they agreed.
And so we began. We organised to stick the saline drips to the doorframe using a clothes hanger. Each morning I would go round to the house after morning surgery, and the district nurse and I would set up the drip with the clomipramine, and slowly infuse the whole mixture over about an hour. During that time I sat next to the bed and, after the first couple of days of awkward silence, we began to talk. Part of that was to check any perceived reaction to our infusion, adverse or otherwise. Part was about the birth, her baby, her family history, her hopes for the future. We checked her pulse at regular intervals, but not once in the ten days did we get anything like an adverse reaction.
About day 7, both the family and the district nurse began to report radical change. Sleep and appetite had improved, her demeanour was happier, her interest in and attention to her baby was far more positive, and other family members seemed relieved and happy. She had been up much more during the day focused on the needs of the baby and her daily chores. After day 10 I switched her to a small maintenance dose. Her cardiac status and her ECG showed no observable difference to the first time.
None of the family called me in over the next few weeks, but I popped in to see her and the baby briefly once a week, and then we saw her at the surgery from then on. Her two weekly, and then monthly, visits were always brief and filled with the happy development of her baby.
I was never to need to use clomipramine again, and it was only some years later that I was by chance to read a research report of several deaths from cardiac malfunction during the early intravenous treatment phase of treatment. I shuddered (as I do now recalling the episode) at what risks I had taken in my youthful enthusiasm.