Monday
GK is a 50-year-old woman who came to me for the first time a couple of weeks ago describing a long history of depression punctuated by hypomanic episodes. Her thoughts were racing a bit, and her spending and sexual impulsivity had been threatening her marriage. We began a combination atypical antipsychotic/selective serotonin reuptake inhibitor, and within days she reported feeling “clear and at ease,” a mental state she had not experienced “in 4 score and 7 years.” Parenthetically, I think she was a Lincoln aficionado, though not well versed in mathematics.
Tuesday
The recession has undoubtedly been a source of stress for many people. But here, in a community that is home to some of the big banks, you can imagine that there are a few folks whose stress level is particularly acute. It is my opinion that many of these high-intensity organizations have cultivated a group of hyperthymic worker bees—energetic creative souls who get by on 4 hours of sleep at night. Under current conditions, a few of these individuals are having difficulties. BT was one of those. This 45-year-old banker had been self-medicating with alcohol for the last 10 years (at least). Despite interventions with his now ex-wife, a hepatologist, a psychiatrist, and myself, he continued his heavy drinking, and I just received word that he died of fulminant hepatic failure. This was an otherwise really nice guy, a hard worker, who gave to his community, had lots of friends, and, ultimately, couldn't stay away from the bottle. How tragic.
Wednesday
Another financier was in today because work stress was becoming overwhelming. He reported symptoms of generalized anxiety but was wary of medication because he needed to maintain his edge—if he was too relaxed, he worried, he might be passed over and laid off at work. Between his sertraline and a counselor who is available on weekends, I hope his fears will be allayed. That said, he remarked that, if he shows up at work in his pajamas, he will be upset with me. (Language edited for family consumption.)
Thursday
I received a telephone call today about a teenaged patient of mine who had been admitted to the hospital for suicidal gestures. I saw her a few weeks ago; at the time, she had discontinued her lamotrigine because she didn't feel as creative as she used to and, not surprisingly, her mood had deteriorated. Despite regular therapy, she hasn't seemed to develop the insight necessary to help cope with her problem. Hopefully that will come soon, as the strain on her and her family is clearly evident.
Friday
As the academic year comes to a close, it is hard to tell who is happier, the teachers or the students, as both experience a sort of emancipation. I will say this, the look in the eyes of a mother of 6 (aged 7–18 years) tells me she is not one looking forward to the idyllic days of summer. I refilled her alprazolam, which she always uses sparingly, but more often during June, July, and August. ♦
Editor's Note
Dr. Wolff is a board-certified family physician in private practice in Cornelius, North Carolina. He finished his family practice residency in 1997. He has graciously consented to share stories from the trenches of primary care. While his practice diary is taken from actual patient encounters, the reader should be aware that some medication references may represent off-label uses. Identifying details have been changed to protect patient confidentiality.
We at the Companion are certain that these vignettes will inform, entertain, challenge, and stimulate our readers in their effort to address behavioral issues in the everyday practice of medicine.