I looked at my patient again, this weary young woman, and realized she had not been making eye contact with me. She wasn’t really looking at the translator, either. It struck me that what I had mistaken initially for shyness, or perhaps nervous deference to a medical authority figure, was an aura of sadness. 

Her face was drained of emotion. Her slumped shoulders, the absence of gestures as she spoke, and the lack of animation in her voice all amounted to a flattened affect. You didn’t have to be fluent in Spanish to sense that. A red flag began to flutter in my mind. I asked the translator to ask Maria how things were going at home.

Clearly it wasn’t modesty that had caused Maria to wear long sleeves on a hot day.

In a matter-of-fact tone, Maria shared that she had two young children, the youngest less than 1 year old. They were healthy, but they were a lot of work. Her husband provided little help in taking care of the household or the kids. He drank more than Maria thought he should. She said she was feeling overwhelmed. When I asked her if she often cried, she nodded.

“Sometimes people who feel terribly sad all the time wish they could just end it all,” I said. “Have you ever felt like that?” 

Maria answered me by pulling up the sleeves of her blouse to show us healing lacerations, perhaps two weeks old, across both wrists. The scars were clean and free of infection. Gently I asked, “Did you do this?” She stared at a spot on the floor somewhere between the translator and me, and I heard her softly answer, “Sí.” 

She had let us in on her secret. Her desperate need to be free of the way she was feeling had overcome her sense of responsibility to be there for her children—for a brief period, at least. 

Clearly it wasn’t modesty that had caused Maria to wear long sleeves on a hot day. And now we knew why she felt tired.

Unlike some who wouldn’t hesitate to share stories about their psychiatrist, people living with mental illness in rural cultures, especially in the developing world, must often bear the added burdens of shame and guilt. 

Social stigmas attached to psychiatric problems, the result of superstition and prejudice, force mental illness into hiding. This was the reason Maria had waited to be the last patient to be seen that day—so she would be less likely to encounter neighbors and friends who might confront her with uncomfortable questions.

Unshakable feelings of sadness, low self-esteem, and loss of interest in pleasurable things are all typical of depression; so are physical complaints, like disrupted sleep, loss of appetite, and fatigue. And in the developing world, it is these latter complaints, suggesting a socially acceptable physical disorder rather than a psychological one, that are offered up by depressed patients for the doctor’s consideration. 

Thus, recognizing depression, a diagnosis all too often missed in the first world, becomes even more challenging among populations that are poor, isolated, and uneducated.

Donated Drugs

So what could I offer this suicidally depressed mother of two who lived far from any kind of professional psychiatric support? Not much, unfortunately, but maybe enough. I first explained to her what I thought was wrong. I wanted to dispel some of the widespread misconceptions about psychiatric illness, which I was certain her upbringing had embedded in her. 

Serious, even life-threatening illness doesn’t always require high-tech tools to diagnose.

She needed to know that this was not her fault, that she was not weak or somehow damaged, that this was a common illness, and that she would get over it. And because I earnestly wanted her to understand and accept what I was telling her, to add weight to my words I even pulled out that old bit of snake oil: “Trust me, I’m a doctor.”

From the clinic’s stock of donated drugs, I prescribed an antidepressant medication to Maria. What I didn’t have to offer her was a place to go for counseling or ongoing psychiatric care.

Maria had come to the clinic alone, but she had a sister and a close friend. I urged her to discuss what we had told her with these people—that this was an illness, and that the doctor had given her medicine to help her. She nodded. 

I searched her face for some brightening of her aspect. Maybe she understood. Maybe I was expecting too much too soon. I asked her to return to the clinic next month for a follow-up visit so a doctor could see how she was doing. I hugged her and again reassured her that she would get over this. 

In less than an hour, I was looking down at the majestic Sea of Cortez from 5,000 feet, heading home.

Two months later, a colleague told me that Maria had come back to the clinic. She was feeling much better and had requested refills of the medication. Her improvement reaffirmed a lesson I often share with my students. Serious, even life-threatening illness doesn’t always require high-tech tools to diagnose. Sometimes all it requires is an ear. Listen to your patient—she’ll tell you what’s wrong.