Post by Shy Ted
Small regional town in the tropics, population less than 1000, part of my occasional outreach travels as a mental health nurse. Referrals were received occasionally from the local GP or hospital and it was easy to make a quick trip there but what was essentially a trip to see 2 people usually became a full clinic of 8 or more.
Most of them weren’t mental illness as such but it adds interest and helps things out locally. Gamblers, drinkers, druggies, brain damage, you often never knew what was next. It had been a long day and I was just saying goodbye to everyone when the Indian GP, a delightful lady, working where Aussie GPs don’t want to, asked for a quick word.
“I’m just stitching up Mr B, again. He’s got epilepsy which we can’t control, he has about 2 fits a week and they’re managed OK at home but his wife becomes absolutely frustrated with him and this time she’s hit him with a broom, big gash to his head. Really I should report it to the police but neither of them want that. To tell you the truth he’s the most annoying person I’ve ever met so I’m not surprised she hits him. Can you see them?”
Inwardly I groaned. People who have just had a head injury we wouldn’t be inclined to see until after a monitoring period so I said I’d see Mrs B, hoping for a quick chat and maybe an appointment at the next clinic. Quick look at both their files, hers small, his massive. Married 35 years.
Introductions. A completely ordinary outback Caucasian lady. “Can I be blunt, Mrs B? The doctor says you’re husband is the most annoying person she’s ever met. Is he?”
“His epilepsy is getting worse over the years and he’s always doing things he doesn’t remember. I can never find the car keys or the cutlery because he’s put them somewhere stupid. He talks nonsense and is always searching for funny smells that don’t exist. The neurologist says it’s his temporal lobe and they can’t control it so I just live with it”.
Another internal groan, the reality of life sometimes. “How often do you hit him compared to how often you don’t hit him?”
“Oh I only hit him when my periods coming, the rest of the time I just live with it. For better, for worse…” What? What!
“Like premenstrual tension?”
“Oh, yes. Had it since a girl. I was wild back then and everyone was scared of me because of how I’d be in that week before my monthly. Mr B was the only man who dared take me on. He was pretty weird back then with his epilepsy but he’s a good man and has always looked after me”.
“How does he handle you in that week normally?”
“Oh, he just gives me a hug”. I asked her to elaborate. “When I get wild he just hugs me but so tight I can’t move and then my anger passes and we give each other a kiss. It works if he’s quick enough but if he’s not I hit him with something”. Me – “like..?” “Something big, what ever’s at hand”.
I couldn’t believe it. I covered all the other bases in a few minutes, nothing. “You call it premenstrual tension. We call it premenstrual dysphoric disorder. Want to try some Prozac?”
“Will it help?”
“Should do. One a day or just one a day in your “week”.”
Quick chat with the doctor, notes to follow. Back to home town. Multidisciplinary team meeting the next day to discuss cases. Eager young psychology graduate wants to do cognitive behavioural therapy. Eager young graduate social worker says counselling. Tired, experienced old Ted says let’s just wait and see, much to their annoyance, they’ve got degrees and know everything! Then come the rules about “cases”. Are you going to see the person again? If so, you have to open a “case” and provide a minimum level of contact. The rules were devised in cities, by academics, partially to help secure funding but mostly to make life more difficult for clinicians. If you don’t “open” a case you “close” it and usually give them a call to say so, leaving them with the GP. There are so many marginal cases where you’re intellectually curious as to what happens next, did the treatment work? and the rules don’t accommodate this. Every week at the review of open cases I had to justify my non-actions to these twerps. The next visit was 2 months later and called in at their house unannounced. Both were beaming.
“How did the Prozac go?”
“Oh, it’s wonderful. I just take one when I need and I’m good,” said Mrs B, “and when Mr B’s not having a good day with his epilepsy I give him one and he’s good. I told the doctor and she’s happy with that”.
There’s no pharmacological reason why Prozac, a SSRI antidepressant, would improve epilepsy but it’s marvellous for stress so maybe there’s something in that. The next case review was joyous. 1 assessment, 2 “cures”. Eat sh*t, graduates. I didn’t visit again for 3 months but I did seek out the doctor and asked about the “B’s. “I haven’t seen them except around town. They were holding hands like a young couple!” Which I duly reported at the next case review. To scowls of disapproval.
Shy Ted considers himself a bit of (not a lot of) a veteran of rural and remote life, mostly, but not always, nursing. Most of what you might read about in the media, other than the superficial headline such as doctor shortages, is nonsense. It’s interesting, challenging and rewarding and not for the faint-hearted or ideologues. Where necessary, names have been changed to protect identity.
Prozac. A simple solution to all problems?
It may be that Mr and Mrs B had serotonin deficiency that triggered irritation or depression at certain times of the month or any other.
But if you have an actual medical condition and your doctor cannot diagnose your case, your symptoms can get tossed into the “it’s all in the mind” category. Doctor then decides that you need the mood-elevating anti-depressants to sort you out. Even when the problem is related to something going wrong in the physical body not a mental illness.
Another valuable insight into a world most of us never see, thanks Shy Ted.
In the 80’s, new job, inherited a talking therapy group of people we called the “worried well”. In the absence of a cure the theory was that talking would lessen whatever ailed them. Clients were depressive and/or anxious types and had been attending for years. One day one of them came to the group to say goodbye – “My GP put me on Prozac. I’m fine now”.
Over the next few weeks they all dropped out, having been to their GPs and asked for some. It was like a miracle. Big fan of the SSRIs. Not a cure-all for everyone but that’s why they’re prescribed in vast quantities.
Thanks Shy Ted, always an educational read.
I was about to write what Siltstone said before I reached his comment. Unreal to us normies, but for Ted’s compelling narrative.