A patient writes: “I am dead inside.” when a mental health issue requires a second opinion

The Personal Health Navigator is available to all Canadian patients. Questions about your doctor, hospital or how to navigate the health care system can be sent to AskLisa@Sunnybrook.ca

The Question: I am a man who suffers from severe depression. I seem to be medication resistant, as I have tried many. They work for a while and then they stop working. I have been having a bad month. Started near the beginning of December. Currently I am taking Citalopram and Ritalin for ADHD. I am at my wits end. I am dead inside and just waiting for the outside to catch up. I don’t take care of myself at all. The psychiatrist I was with just kept trying different medications, so I quit seeing him and now my doctor handles prescriptions. I have trouble communicating what is going on inside me as I don’t want to upset anyone and have them freak out. That is why I am using e-mail. Any help, advice would be greatly appreciated. I am even willing to be locked up, to force myself to work on me. 

The Answer: Your question demonstrates the pain and suffering that occurs when an individual has a mental health issue not adequately addressed. The moment I read your e-mail, I contacted Sunnybrook’s Psychiatrist-in-Chief, Ari Zaretsky, who specializes in mood disorders and cognitive therapy. He suggests that you return to your family doctor. Explain the symptoms impairing your function have not responded to your psychiatrist’s interventions.

“He needs a fresh look so I would suggest he get an evaluation from another psychiatrist to evaluate his diagnosis and treatment regimen,” Dr. Zaretsky said in an interview. “Even if the diagnosis is, in fact, correct and in keeping with the first psychiatrist’s assessment, most patients need a combination of medication and psychotherapy or psychosocial interventions.”

It’s not uncommon for patients to have more than one diagnosis. You describe yourself as having severe depression and Attention Deficit Hyperactivity Disorder, [ADHD] the latter of which is characterized by inattentiveness, over-activity, impulsivity, or a combination of those three symptoms.

Every adult who has this disorder has had it as a child, though many children may not have been diagnosed. Only about one-third of diagnosed children will grow out of the problem by adulthood, typically after the central nervous system has matured and brain has become fully wired, around age 20, according to Dr. Zaretsky.

That, in part, is why Dr. Zaretsky screens every new patient referred to him for ADHD, which affects five per cent of the population, typically more males than females.

“ADHD is common and often missed. People tend to focus on the mood disorder,” he said. “…You should target the ADHD with psycho-stimulants and cognitive behavior therapy that teaches the patient to become more organized and to be able to manage themselves more effectively.”

Chronic inattention, distractibility, forgetting appointments, severe procrastination and impulsivity are common symptoms of ADHD. In some cases, those with ADHD have difficulty holding down jobs due to their intolerance of boredom the need to do tasks that require attention to detail.

Typically, in cases where patients have the two diagnoses of depression and ADHD, the depression is treated first in order to provide the motivation and energy required to tackle the chronic ADHD problems.

Dr. Zaretsky said a day treatment program would be critically important to your treatment. In such a group, there are structured activities that can help you learn life skills. He also recommends you exercise, if you aren’t already doing that.

“Even though it is very difficult to be motivated to exercise when you are depressed,” says Dr. Zaretsky, “aerobic exercise is very beneficial to the brain and leads to the growth of new neurons.” If you are self-medicating with drugs or alcohol, to soothe your distress, refrain from both, as it will compound your issues in a “very significant way,” he said.

To sum up, please visit your family doctor, request another referral to a psychiatrist for a fresh look at your diagnoses, and request that you be enrolled in a day treatment program in your area. Thank you for your bravery in writing this letter and describing your symptoms so articulately.

Lisa Priest is Sunnybrook’s Manager of Community Engagement & Patient Navigation. Her blog Personal Health Navigator provides advice and answers questions from patients and their families, relying heavily on medical and health experts.  Her blog is reprinted on healthydebate.ca with the kind permission of Sunnybrook Health Sciences Centre.  Send questions to AskLisa@sunnybrook.ca.

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  • Recruiting Animal says:

    “It’s not uncommon for patients to have more than one diagnosis.”

    Jerry Sugar, a doctor at CAMH, told me that it’s very possible that every psychiatrist you speak to will give you a different diagnosis and recommend a different treatment.

    And anyone who’s met a few knows that this is true.

  • Recruiting Animal says:

    Good article. However, when I took a friend to Sunnybrook (in an ambulance) we stayed in the emerg all day from about 7am till 5pm.

    Then a young psychiatrist came down and said the person is very sick but he won't admit her.

    Why? Well, he said, she'd been to CAMH emerg recently as well and they didn't admit her. Instead he gave her a brochure to a house at Bloor and Church where they let you stay a few days to relax.