I had to read the nurse’s note twice. “Patient complains he is dead,” it said.
I looked over at room 4B, the emergency room’s psychiatry unit, where an elderly man in a terry-cloth robe was sitting, head down, shoulders hunched. He looked depressed and toothpick thin but clearly alive.
I walked into the room, flipping through his medical records. The patient was an 82-year-old widower who resided in a South Carolina assisted-living facility nearby. He had a history of hypertension, mild senile dementia, and depression. He was taking several medications, including an antidepressant. His wife had died three years ago. His health had been stable until three months ago, when he began losing weight. During that time, he had lost more than 10 pounds. Aside from the recent depression, he had no history of psychiatric illness.
“Hi,” I said to the man. “How are you doing?”
“Leave me alone,” he said irritably, massaging one hand with the other. “I’m dead.”
I didn’t know what to say next, so I said what I usually say: “How long has this been going on?”
He kept wringing his hands. “Since about 7:30.”
“Yeah. Just after breakfast.”
“Oh,” I paused to find the right words. “How do you feel now?”
He lifted his head to look at me, clearly irritated. “I’m dead. How do you expect me to feel? Just look around. Can’t you see? Evil and death. It’s everywhere. It’s coming out of the walls. It’s all over. Evil has taken over the world.”
I didn’t know how to categorize the chief complaint. Was it physical? Psychiatric? The patient was delusional, technically a psychiatric complaint, but delusions in the elderly often result from organic disease. The patient could think he was dead for such reasons as simple pneumonia, increased pressure in the brain, or an abnormal accumulation of copper. All of these conditions can cause delusions.
I ordered a number of tests for organic imbalances that can affect mental function. But an hour later, I was no further along. All the results proved normal, and the patient only looked worse. He sat rocking steadily, back and forth, in anguish.
Severe depression is a soul-wrenching, psychic black hole. Hippocrates described it first: “The patient feels something like a thorn stinging his innards. He flees from light and from people, loves the dark, and he is caught by panic. He is terrified and sees frightening visions, dreadful nightmares, and sometimes dead people.”
Doctors once called this condition involutional melancholia—the deep, deep despair of old age. Modern medicine has folded the diagnosis into the disorder known as major depressive episodes with psychotic features. But keeping the ancient view of involutional melancholia as a distinct entity is useful because it underscores that the elderly are particularly vulnerable. Among this group, depression can be punishingly severe and, in some cases, nearly impossible to treat successfully. This patient’s prognosis was not good.
The social worker had a different take. After interviewing the patient, she chirped, “Well, he’s a bizarre little guy.”
“I think he’s very depressed.”
“Well, whatever . . . I think he can go home, and we’ll send a social worker.”
“That man,” I told her, “needs to be admitted to the hospital.”
“Because he’s depressed? But he’s not suicidal or homicidal.” Impulses to kill oneself or others are the two main symptoms that mandate hospitalization.
“Of course he’s not suicidal,” I shot back. “He doesn’t need to be suicidal. He’s already dead.”
“I don’t think he’s depressed,” she said. “I think he’s just senile.”
Rather than answer her, I sat in silence, my head in my hands. Depression in the elderly can mimic many conditions, including Alzheimer’s disease. I had learned this firsthand when my father entered his worst stage of Alzheimer’s. In addition to being confused, he became very despondent. “I’m watching myself die, aren’t I?” he once asked. I thought his despair was just a normal reaction to the trauma of losing one’s bearings. He tried an antidepressant, though, and after six weeks of treatment, his mood markedly improved. He remained as confused as ever but somehow not as miserable. Despite the disease, he became somehow more like my dad. Depression seemed to take more away from him than Alzheimer’s did.