Thursday, May 21, 1998
2 pm. First Session with Samuel Eldrich. I met today with Sam Eldrich, a boy almost 18, who's about to graduate from high school. Sam is troubled by depression and self-loathing, giving rise to suicidal ideation. I don't believe that Sam is an imminent suicide risk--he doesn't appear to have any fixed plan. Sam was emotionally labile, crying frequently during the session. He seemed to have a diminished ability to concentrate, although he seemed to improve towards the end of the session. He presented signs of psychomotor agitation with repetitive nervous features--drumming his fingers and pulling at his shirt--and he complained of persistent fatigue. His speech was rapid, and given in a high-pitched staccato whine. And, of course, he suffers from recurrent suicidal ideation without specific plan, combined with feelings of worthlessness and excessive and inappropriate guilt which seems almost delusional in character. He was also able to laugh and joke at times, which is somewhat atypical of patients suffering from depressive episodes. But I am concerned that the apparent trigger--Sam's bereavement over the death of his grandfather and his inability to care for his grandmother--masks a clinical depression. I saw no evidence of bipolar mania so I'd guess his depression is unipolar. The med school mnemonic was "Depressed I Was Stuck Memorizing Extremely Grim Catagories of Sickness"--Depressed mood; Interest; Weight; Sleep; Motor activity; Energy; Guilt; Concentration; Suicide. The mnemonic came in handy while listening to Sam. I want to conduct a suicide assessment of Sam during our next session. If I'm wrong and he is an imminent suicide risk, I must consider an involuntary commitment. But currently I'm leaning towards taking a somatic approach--possibly fluoxetine.

Thursday, May 28, 1998
2 pm. Second Session with Samuel Eldrich. Sam was calmer during this session. His voice was deeper--an attractive baritone. He had none of the staccato whine that I noted last session, perhaps he was less agitated. I also noted fewer nervous gestures, though he still found it difficult to make and maintain eye contact. Sam found himself thinking about his grandfather's death over the Memorial Day weekend. He told me, when his grandfather died, that he exhibited tremendous grief for a period of approximately three months. Then, in one day, he consciously made an effort to shake off the effects of grief and was successful. But on Memorial Day, he began to have "grief flashbacks." Sam describes his grandfather as a sainted relative, beloved by his entire family. He worked creating an insurance business which was taken from him by the scheming of a nephew, now hated by the rest of the family. But Sam now compares himself to his grandfather and comes to the conclusion that he's a failure in comparison. Sam sees it as a failure in himself that he has sought psychiatric counseling. Sam sees himself as the recipient of economic and family benefits that his grandfather never knew, and yet Sam finds it impossible to cope with the adversity in his life. I pointed out that Sam's grandfather had more experience in coping with adversity than Sam did, which seemed to give him some brief comfort. However, Sam feels worthless when he tries to live up to his grandfather's standards. I told Sam that he is learning now a set of skills to help him address future adversity in a rational way. I conducted a limited suicide assessment of Sam and convinced myself that he wasn't in any imminent danger of killing himself. He has no fixed plan and treats suicide as an attractive fantasy rather than as a current option. I broached the idea of treating Sam's depression using drugs, and he was open to the idea. During the next session, I'll prescribe 50 mg. Sertraline (Zoloft), a serotonin reuptake inhibitor, once each morning. I'd like to give the Zoloft a six week trial.

Thursday, June 4, 1998
2 pm. Third Session with Samuel Eldrich. I spent most of the session continuing my suicide assessment. Sam has genuine feelings of worthlessness that have a delusional character brought on by clinical depression. I don't think that he is in imminent danger of following through on his suicidal ideation. But if there is some triggering event, Sam is seriously at risk. He told me about studying "The Iceman Cometh" in a literature class and being profoundly affected by a scene in which a character's friends react with contemporaneous indifference to the man's suicide. Sam became obsessed with that scene and he felt that it triggered his last depressive episode. Sam said that he felt envy--he'd like to slip away without anyone noticing or caring. However, I find that difficult to believe. Beyond Sam's delusional sense of his own worthlessness, he also has a series of elaborate suicide fantasies. One thing that I found somewhat encouraging was that Sam wants to be careful to avoid brain damage. Apparently, the prospect of living as a vegetable is much scarier than death. Sam seemed a bit hostile during this session, but he attributed it to finally allowing me to see his thoughts "unedited." Sam agreed to taking an antidepressant, so I prescribed Zoloft, 50 mg. qd. for a six-week trial. Sam seems to be quite fixed in his current thought patterns. He's allowing for little chance that a different perspective will change any of his conclusions on his own worthlessness.

Thursday, June 11, 1998
1 pm. Telephone Conversation with Samuel Eldrich. Sam called to cancel the session. He seemed really anxious and went out of his way to assure me that he was doing okay and was taking his medication. I reiterated that it was important for Sam not to miss his sessions right now, and he promised me that he would try to make it in the future. He canceled today's session because a job interview conflicted with the session. Sam said that he felt the medicine was beginning to work, which I find unlikely given that he only started a week ago. I got a deep sense of anxiety from Sam. I would have thought it was just a reflection of his feelings regarding the upcoming interview, but he was more relaxed when he talked about the interview than he was during any other point in our conversation.

Thursday, June 18, 1998
2 pm. Fourth Session with Samuel Eldrich. We're at a dangerous time with Sam. He's been taking Zoloft for a couple of weeks now, but isn't yet feeling any effects. What he is feeling is a dissatisfaction with therapy generally. Sam is trying to hold tightly to his cherished notions of being a worthless individual. He can't conceive of another way of thinking about himself--which is particularly interesting given the delusional nature of his current self-perceptions. Clinical depression sometimes leads patients into a particular mode of thinking which is easier to fall back into than learning new cognitive rules. I believe that even after the Zoloft has taken effect, it will be necessary to use cognitive therapy to teach Sam another way of thinking about himself--giving him useful thoughts to put in place of the old, destructive ones. As we spoke, Sam's voice became low and almost menacing with anger. He took the position that his true personality was the defective one that was low on serotonin. I took the position that his depression was the result of a physical chemical problem in his brain that the Zoloft would address, much like insulin assists diabetics. Sam tried to make a distinction between purely physical problems like diabetes and personality altering attributes such as those caused by chemical imbalances in the brain. That's a slippery slope that many far wiser than Sam or I have struggled with for some time. I found it interesting that Sam is fighting for a continuity of personality traits which he then uses as part of his argument for being a defective, and thus worthless, individual.

Thursday, July 2, 1998
1:05 pm. Telephone Conversation with Mary Eldrich respecting Sam Eldrich. I spoke with Sam's mother. Nominally, she called to tell me that Sam wouldn't be coming to his session. He's swollen and in pain after having his wisdom teeth extracted. I remember when I had mine extracted in the second semester of my first year of medical school. For a month, I couldn't eat anything more substantial than "Chicken Sludge" which I made in a Cuisinart. I sympathize with his reasons for missing his session. Sam was obviously in the room during the first portion of the telephone call and Ms. Eldrich seemed deferential to him. After she got out of his earshot, she pleaded with me to give her some indication of Sam's prognosis--she really sounded quite desperate. I told her that other patients I've treated who share Sam's problems have done very well, and that Sam should do similarly if he's willing to apply himself to the therapeutic process. She seemed pleased and somewhat relieved. Now, if only I can make it really happen.

Wednesday, July 8, 1998
4:20 pm. Telephone Conversation with Mary Eldrich respecting Samuel Eldrich. Ms. Eldrich called me to cancel Sam's appointment again. She told me that Sam is having complications following oral surgery to remove his wisdom teeth. Sam's gums are infected and the oral surgeon told Ms. Eldrich that the infection was due to Sam picking at them. While possible, I think it is also possible that Sam's gums became infected as a result of surgery and that the itching resulting from the infection has driven Sam to pick at the wound. I told Ms. Eldrich that theory, and she seemed somewhat relieved. Ms. Eldrich didn't mention whether or not Sam is taking antibiotics for the infection, but I assume that he is. Ms. Eldrich said that she felt personally guilty for not spending enough time with Sam because of her work obligations. I gave her permission to stay at home with him, if she wished. I'm concerned that Sam might use his dental problems as an excuse to avoid taking his antidepressant medication.


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