Sunday, March 24, 2013

Depression



"I'm Not Driving Anymore" by Rob Dougan

A/N: Obviously, the title of this story foretells certain things, but putting that aside, what images does your mind envision when you hear the words, “African mission hospital”? Laparotomies by the dim light of a torch? Crowded wards of mothers with their children on quinine IV drips resting on flimsy mattresses? Psychiatry probably isn’t the first thing that comes to mind. And, to be truthful, it is still an underrepresented area of care in most of Africa. As the populations become increasingly urbanized, some mission hospitals in or near the cities must be willing to adapt to the ever-increasing variety of ailments. It isn’t all malaria and typhoid now. What follows is one of my experiences trying to navigate psychiatry in a foreign culture.

“Hear my prayer, O LORD;
let my cry for help come to you.
Do not hide your face from me
when I am in distress.
Turn your ear to me;
when I call, answer me quickly.
For my days vanish like smoke;
my bones burn like glowing embers.
My heart is blighted and withered like grass;
I forget to eat my food.
Because of my loud groaning
I am reduced to skin and bones.
I am like a desert owl,
like an owl among the ruins.
I lie awake; I have become
like a bird alone on a roof.”
Psalm 102:1-7


I remember the first day I met Pat*. Petite. Poised. Precise. Unlike the many inhabitants of Buea, she was strikingly distinct in her appearance. A slender bone structure with elevated cheekbones, light brown skin, and shiny curly black hair coiffed in immaculate braids tracing ribbons on her scalp indicated her foreign heritage.

 *(names, places, and certain other details have been modified)

If her external appearance hadn’t given her away, her accent of soft, distinct syllables, clear and musical, would have revealed her outside ancestry. “Where are you from?” I inquired, curious as to her origins.

“Botswana,” she replied in refined English tones that were easy for me to understand, a rarity during my earlier days in Cameroon. She smiled mischievously. “Do you know where Botswana is?”

“Well, I must confess that I do not.” I gave her a wry smile and bent over my world map on the desk between us to search out a new country and expand my geography knowledge.

She chuckled and rearranged her purse, setting it aside on the rusty chair next to her. “Here,” she pointed out the small African country nestled next to its domineering neighbour in the southern part of Africa all the while gazing at the map upside down.

“Ah, I see,” and nodded in recognition of the country. I raised my head and took in her facial features again. Very similar to the Ethiopian aquiline beauty oft admired in fashion magazines. Her eyes crinkled upward at the corners and smiled back at me, amused at my meagre geographical knowledge but obviously pleased at the interest I showed.

“Someday you should come visit,” she invited pleasantly.

“Maybe I will,” I replied with the cautious enthusiasm of one who loves to travel and experience new cultures yet realises there are only so many places one can see in a lifetime. However, Botswana now stood a much higher chance of getting on that list!

“How did you come to Cameroon?” I asked the next logical question as she obviously was still fond of her motherland.

“My husband,” she replied matter of fact. Then her mobile buzzed and she motioned an apology as she flipped it open to answer the caller. “Yes, mama…I’m at the hospital…I’m coming…” Tone and body language indicated the person on the other end of the conversation might not be the most amiable caller. With a tired sigh, she concluded the conversation and stashed away her phone, turning it off as she turned her attention back to our consult. “Sorry,” she shrugged her slender shoulders with an apologetic gesture. “It was my mother in law. She has to know where I am. If I’m gone for more than an hour she calls.”

I nodded a sympathetic gesture.

In reply she returned to my original question, “My husband is a business man and travels a lot. He was in Botswana. We met and fell in love there. He’s Cameroonian. All his family is here. So,” and she gave a poignant look of accepted destiny, “that’s why we’re here. We are building a place up in Buea Town.”

After our introductions, we eventually came around to her medical reason for consulting. Although I cannot recall the problem, I assume she was content with the advice as she continued to remain a client of our health centre and brought her children when they were sick as well. . I remember exchanging emails and finding myself intrigued by this lovely lady who painted a picture of poise and grace under pressure. Smart. Modern. Managing as best she could in a new culture. Fascinating.
~O~
Life goes on. Events happen. Time marches forward. One day, Pat showed up in my clinic in order to consult again. Nausea. Vomiting. Loss of appetite. Weakness. Dizziness. Hum? I asked her when her last menstrual cycle had been. “Any chance that you’re pregnant?” I inquired as we began our conversation in the office to go over her history.

“Yes, I think I am,” she gave a shy and happy smile in spite of her ill health.

A urine pregnancy test a few minutes later confirmed our suspicions. Pat was quite pleased. It would be her third child. She had two other biological children in addition to three older adopted children from her husband’s previous liaison.

It was a good thing that Pat was so delighted about the new addition developing gradually, in the perfectly controlled process of time, inside her womb. In spite of our best efforts, she struggled in an endless battle against pregnancy-induced nausea and vomiting and the resulting fatigue.  Each antenatal check up ran along similar lines. “Pat, you’ve lost a kilogram. What happened?” I was concerned at how this already tiny, forty something kilogram, Botswana lady could manage to grow a healthy baby in her nutritionally compromised state?

“I know, doctor.” She always gave me a brave apologetic smile. “It’s just so difficult. The food here…” her voice drifted as she remembered her native traditional dishes. With a wistful expression, clear almond brown eyes staring off into unseen places and senses smelling her homeland dishes, she related her struggles with getting used to the very different foodstuffs her Cameroonian mother in law cooked. “She is constantly telling me to ‘eat’. She tries to force me.” She related her recollections of such with a shudder. “She doesn’t understand…” her voice faded into silence. 

I empathised with her and gave her the freedom to voice her frustrations and grievances against her current situation in the privacy of our consulting room. “For the baby’s sake, try to eat more. Small, frequent meals. Small snacks. Groundnuts, perhaps?” I spoke with concern for both mother and yet-to-be-born infant. As she left her antenatal appointment, we hugged. A hug of encouragement and hope. A small infusion of my strength and concern to bear her up against the daily struggles of dealing with an overbearing mother-in-law, an absent husband, a demanding job of supervising the building of the family home, all in the face of a medically difficult pregnancy. It was not easy.

Somehow she survived her third and most difficult pregnancy. The resiliency of the human spirit against earthly antagonistic forces is extraordinary. There are certain people that seem to glow all the more brilliantly in the polishing harshness of reality. Pat was one of these people. In spite of her mother-in-law’s harassments, constant phone calls tracking her every movement, and pregnancy fatigue – in spite of everything – she made it through all nine months of pregnancy and delivered a beautiful, healthy baby girl in the middle of the rainy season. A two point nine kilogram beam of sunshine and joy breaking through the billowing storm clouds that stacked up against the mountainside of Buea. Since I was away on annual leave during the momentous event, it wasn’t until a month later that I was introduced to the new addition. It was a joyous reunion consisting of pictures, smiles, congratulations, and thanks all around.
~o~
After the birth of her daughter, Pat slipped from my mind. I occasionally thought of her and wondered how she was coping but I rarely heard from her. On her part, the construction on their family home, the new baby, the routines of daily life and raising six children, kept her preoccupied.

It is the unfortunate fate for one who works in the medical field that patients typically only reappear when a health crisis hits. (An occupational hazard that comes with the profession). So it was that several months later, I glanced out at our packed waiting area, not unusual for a Monday. Men and women, old and young, squeezed together on our artificial leather padded benches situated against the walls. Small children dashed here and there, some grasping small plastic baggies of chin-chin or groundnut snacks in their grimy palms leaving trails of crumbs for the sparrows wherever they toddled. Glancing out into the sea of familiar organised chaos and trying not to calculate how far behind I was in seeing patients, I caught sight of Pat. She met my eye and gave me a quick smile. She looked alone - and tiny. Dressed neatly in jeans, ruffled blouse under a wrap-around sweater, and perfectly applied make up with a delicate head scarf draped around her face, she presented the epitome of style yet her face held a haunted look of vulnerability.  I was shocked at her naturally slender, petite body that had now shrivelled past thin. Perhaps not emaciated but definitely underweight. I wondered what happened. She didn’t look healthy from my briefest of assessments.

Life has a funny way of tossing all sorts of unexpected hurdles across our would-be smooth path. Sometimes it seems certain people get more than their fair share of these bumps and potholes. Pat’s circumstances were not going smoothly at all. As I listened to her recap a few of the events evolving over the past months, my heart ached for all the pain she was coping with. Emotional turmoil due to an endless string of unfortunate events twisted round her mind and squeezed the peace from her daily routines. The living situation with her mother-in-law remained a continued point of conflict. The stresses of dealing with the problems associated with managing the construction of their new house fell daily on her slender shoulders, each new problem added to the pressure. The support she’d previously received from her husband had now collapsed. She no longer trusted him and more and more he ignored her pleas for help and instead fell under the spell of his mother. A stranger in a strange country with little time to find friends or outside encouragement. She was clearly homesick. Far from her own family in Botswana, she felt abandoned, a sheep among a confusing pack of Cameroonian cultural wolves that preyed upon her weaknesses.

“I’m so tired,” she confessed bleakly. “My mother-in-law keeps pushing. She has to know where I am every moment.” As if on cue, her phone buzzed. She glanced at the incoming caller ID. “That’s her,” she shrugged with a knowing look at me.

I nodded in sympathy. “You need a break.”

“I know, doctor,” she affirmed, “but it’s impossible right now. I can’t interrupt the children’s education. It’s the middle of the school year for them.”

I shook my head at her determination to provide the best for her children. I admired her for it but still worried as she left the office.

Not long afterward, she came to see me again. “I don’t sleep well at night. I can’t eat. I’m constantly tired,” she admitted. “I don’t have any energy.” A few tears welled up and threatened to overflow. She dapped at them with a tissue, careful to avoid smudging her make-up.

As she poured out her sadness and frustrations to me, I brought up the topic of clinical depression. She tearfully acknowledged that she fit the description. “Yes, I know I’m depressed, doctor,” she affirmed with a sad gesture of her hands. After more discussion, she decided to try a small dose of an anti-depressant drug called, fluoxetine, the only option I had to offer her from our limited pharmaceutical supply.

She was faithful to follow up with me for a short while afterwards and admitted that the medication did help. She managed to eat enough despite having no appetite. “I know I have to eat so I can breastfeed the baby,” she acknowledged, “so I force myself to take something.”

“You’re doing the right thing,” I confirmed.

Eventually the school year ended and Pat was able to fly home to Botswana to soothe her tired and homesick soul. I lost track of her after she left.
~O~
It was several months before I saw her again. When I did though I was even more taken aback by her poor health. “I was fine in Botswana,” she informed me. I ate the food I liked. I didn’t need to take the medication.” Without emotion she continued. “But then I had to come back. The children needed to start school again and everything. Now I have too much stress.”

“Are you still breastfeeding?”

“Yes,” she nodded.

I was a bit surprised she still had milk enough to feed her daughter. Yet now the question arose of what to do. There are so many facets to clinical depression. How much is due to external circumstances? How much to internal imbalances of brain neurotransmitters? Each person is unique. There are no easy solutions. Each day was a struggle to survive for Pat. She felt alone and hopeless against the forces of fate. She didn’t have the energy to make new friends or even connect with old friends. I often imagined it was the strong thread of love for her children that anchored her enough to maintain her grasp of reality. Her reason for existence reverberated around them.

Depression is impossible to comprehend as an outsider trying to peer through the impenetrable murky glass wall of dark logic. I couldn’t understand all the strange thoughts and memories that surrounded her. She couldn’t verbalize the tumultuous emotional details that tortured her existence. Instead she gave me the external symptoms. Eternal fatigue. Isolation. Inability to eat. Constant anxiety. Poor sleeping patterns. Feelings of guilt.

The cycle of depression rolls along predictable reinforcing patterns, each building upon the other in an ever-expanding, darkening cloud of hopelessness. Since she couldn’t change many of the aspects of her situation that were unhealthy for her, Pat eventually resumed taking an anti-depressant. “I don’t want to medication because I’m breastfeeding,” she worried. She acknowledged that being alive for her baby was probably more important though.

Sadly, her emotional depression weakened her physical resistance to illness. We saw each other more often than I’d like to report. An endless succession of stomach problems, sniffles, coughs, fevers, and infections. She finally was forced to wean her little girl, as she no longer had the strength to eat enough for two. Mainly I was the spectator and sounding board for her as I watched her spiral hopelessly toward the grave. Her weight dropped alarmingly. She came to me complaining of always being cold, never being able to feel warm. “Everyone tells me it’s because I don’t eat,” she said.

“Well, they’re right,” I reminded her. She wrapped herself in her cardigan a bit tighter while I wished fervently I could take off my white coat and try to cool off a little. A persistent cough took hold of her lungs that refused to disappear in spite of everything. She vomited up normal meals and was reduced to eating baby cereal and yoghurt. “You need to go home to your family in Botswana,” I informed her, quite frankly, one day at our appointment.

“I know,” she conceded. “That’s what everyone is telling me. I just don’t know if I can with the children.”

“If you don’t go back to your mother’s house, you won’t be around for your children,” I reminded her.

She thought about this a moment. “Yes, it’s true. I am working on it. There are so many things to take care of before I can go though.”

“I can write a prescription for you to take holiday in Botswana.”

She smiled at my offer. “I know I need to go back to my mother’s. I was well when I was there before. I could eat and I didn’t need to take medications.”

“You should go sooner rather than later,” I mentioned. Her homesickness, far from the comfort of her culture, in addition to the enormous pressure of building a home and raising six children was too much for her frail health now. “Please go,” I repeated. “You need to for your health. It’s no good here.” There were times when we’d conclude our appointment and I’d wonder if I would see her again – alive.

One day, Pat came to see me. As she coughed her way through our conversation, she related how her husband had recently returned from his most recent trip. “He was surprised at my condition,” she said.

I nodded.

“He agrees that I should go back to my mom in Botswana. Last night he said, ‘what are you doing? You must go back to Botswana…otherwise you want me to send a corpse back to your mom?’”

Rather a blunt statement but essentially true.

“So, I’m going back home,” she continued with the first glimmer of hope in her voice that I’d heard in a long time.

“I’m glad,” I said, genuinely relieved. I didn’t want to have to send a corpse back either. I was thankful that whatever his failings might be as a husband, at least he realised the severity of the situation and agreed with my recommendation.

~O~
The end of this story remains to be seen. Perhaps there isn’t an end. For now though, I am happy to report that she is doing better. I recently received an email from Pat. What follows is an excerpt: “…As for me, thank God I am doing OK. Better than last time you saw me. I am taking my medication and it helps a lot. Thanks to you…. Any way just to let you know that we are fine…”

What will happen next? I don’t know. Her children remain in Cameroon. Her family home is still being completed and will be here. The pressures of her mother-in-law will return when she comes back from Botswana. There are no easy answers. For now she is full of hope again and I can rejoice with her in that. One day at a time…

~o~

A/N: One might argue that Pat was only experiencing severe homesickness. The line between simple homesickness and clinical depression is not always so easy to clearly define. Perhaps closer attention to such ‘homesick’ symptoms in those living in a new culture might be beneficial. A recent survey of over 300 medical missionaries, who have been in their foreign culture for more than two years, revealed significant stress levels and self-reported anxiety and depressive symptoms: “45.3% of respondents have experienced anxiety to self-reported degree of 4 or 5 and 30.6% of respondents have experienced depression to a degree of 4 or 5 (scales both from 0 to 5) (1).”

Psychiatry and the issues involved might not be so remote from African mission hospitals as was once imagined. My prayer is that we can all acknowledge the existence of mental illness in Africa, accept the fact, and work toward a more supportive environment. Perhaps if this article simply makes you think…become more aware…that’s all I can ask.

1.     “PRISM Survey 2011 - Christian Medical & Dental Associations,” accessed March 18, 2013, http://www.cmda.org/WCM/CMDA/Navigation/Missions/Center_for_Medical_Missions/Prism_Survey_2011.aspx