A Lot of Prescriptions (V).

While driving to the clinic, Ms. Blue thought about what she would tell her doctor. She didn’t want to come across as needlessly anxious, but she wanted him to understand how unwell she felt. Was there something wrong with her?

Soon after she was escorted into the examination room, Dr. Refer entered the room.

“Ms. Blue,” he greeted. “How are you?”

“I think I might—well, I’ve been really tired lately.” Ms. Blue paused. “My dad died about a month ago. I haven’t been able to sleep.”

Dr. Refer nodded, inviting her to continue.

“He just didn’t wake up one morning. I guess he died peacefully. He was taking care of Mom, though, and since he died, she’s moved in with my family. I have no idea how he did it for the past five years. She’s… not well.”

“Mm hmm,” Dr. Refer encouraged.

“He had mentioned that, sometimes, she had problems sleeping at night, but he never said anything about her walking around and trying to leave. She gets upset and says something about having to go to work. She can’t get herself together to correctly unlock the door. Thank goodness. But then she screams more.”

Ms. Blue sighed.

“And on those nights when she isn’t going on like that, I find myself lying there, thinking, thinking, thinking. It’s like my mind won’t shut up. I wish I had helped my dad out more. Maybe he would have lived longer.”

“Ms. Blue,” Dr. Refer interjected, “have you been feeling a lot of guilt about his death?”

She looked away.

“I don’t know,” Ms. Blue eventually said.

“With the amount of sleep you’re getting, do you have enough energy during the day to take care of things?”

“Not really. I’ve been taking naps during lunch. The kids have made comments about the coffee I’m drinking after dinner. Even if I had more energy…. I just don’t want to do anything. Things aren’t interesting anymore.”

Dr. Refer nodded.

“Has all of this gotten to the point that you’ve thought about….” He paused and nervously coughed. “… hurting yourself?”

Ms. Blue looked at him and said nothing. He waited, internally wincing.

“I can’t, I can’t,” she said as tears welled in her eyes. “We’ve got kids to support, my husband’s job situation is shaky, and someone has to take care of my mom.”

Dr. Refer coughed again and said, “Let me listen to your heart and lungs, just to make sure they sound okay.” His gaze settled into the middle distance as he moved his stethoscope first across her back, then over her chest. After pushing on her belly, he murmured, “Everything’s fine.”

He settled back onto a chair and looked at her while she wiped her nose with a tissue.

“I think,” he began, “that you might get some benefit from seeing someone. A specialist. Someone who can provide better care for someone in your situation.”

“What do you mean?” Ms. Blue said.

Dr. Refer coughed again.

“Well, some doctors have more experience in helping people who are feeling as… stressed as you are right now.”

She looked at him quizzically. He quickly added, “Your situation is difficult. I can’t imagine how difficult it must be.”

“What are you saying?” she asked.

“Well… I think you might want to consider seeing a psychiatrist.”

She looked at him blankly. He heard the quiet whir of the office ventilation.

She didn’t move. He coughed.

“You think I’m crazy,” she flatly said.

“No, I don’t,” he hastily said. “I think you’re in a tough situation and—”

“You think I’m nuts. You think I need a shrink. Am I really that crazy?” she continued, looking at the floor.

“No, you’re not crazy,” Dr. Refer said. “You’re in a stressful situation. I’m worried about you and I think you would get better care from a psychiatrist right now, given everything that is happening.”

“But why? Don’t you think my reaction is normal? My dad just died, my mom has Alzheimer’s, my husband might get laid off, I want to make sure my kids are provided for—I mean, isn’t this normal?

“Well, yes—”

“Then I don’t need to see a psychiatrist,” she said. Her eyes began to glisten with tears again when she asked, “Can’t you help me?”

Dr. Refer looked at her. He opened his mouth, then closed it again.

“Yes,” he finally said. Her shoulders dropped and she exhaled. Taking out a prescription pad from his pocket, he scribbled something onto the top sheet and handed it to her.

“What is it?” she asked.

“It’s an antidepressant, but I think that it will help you sleep more through the night. In a few weeks, you should feel better. You might experience some dry mouth, headache, or stomach upset, but that should all go away within a few days,” he said. After scratching his head, Dr. Refer added, “Call me next week to let me know how you’re doing.”

“Okay,” she said. “Thank you, Doctor.”

She walked out of the office, feeling tired, relieved, and embarrassed. What did he give her again? Oh, she could look at it later. She just wanted some time alone.

Later, Dr. Refer finished the note for Ms. Blue’s chart.

“Attempted to refer patient to psychiatry for further evaluation and treatment,” he murmured as he moved the pen across the page. “Patient declined referral, but agreed to follow up with me. Provided an antidepressant and asked patient to call me in one week for follow up.”

He dropped the pen on the chart and rubbed his temples.

“I don’t know what I’m doing for her.”

This is part of a series about why some physicians write many prescriptions for psychiatric medications. You can read more stories here.