The many faces of depression.

Mr. John Sneed was only 62, but appeared much older. I thought he looked about 75 years old. He was neatly dressed: a well-pressed, dark blue pin-striped suit, shining black shoes, a white shirt, an impeccable tie knot, and gold cufflinks. He was wearing bifocal glasses and must have shaved that morning. His silvery hair was well styled. He looked uncomfortable, however, sounded hesitant and unsure of himself, and kept apologizing for "wasting" my time. "I am sure you have more urgent patients to attend to, Doctor," he said at least twice. I tried to reassure him and wondered whether he had some type of anxiety disorder.

He had only vague complaints, mostly upper abdominal and generalized aches and pains. While listening to his complaints I reviewed his medical records. He had visited his physician's office several times over the past few months, but his visits had become more frequent during the past weeks. The last time he was in the office, about five days ago, he also complained of upper gastrointestinal problems. My colleague had written a note that he might need to be referred to a gastroenterologist, but apparently had not followed up on this. A blood chemistry profile, complete blood picture, and sedimentation rate were within normal limits.

"It's not so much a pain as it is a discomfort," Mr. Sneed said. I noticed that about one month ago he had complained of chest pain and had a full workup, including a thallium stress test that was entirely normal. About two months ago he had an upper gastrointestinal endoscopy, which was normal, and about three months ago a colonoscopy, which was also normal. I started wondering whether he was a hypochondriac and whether he really might be wasting my time.

Mr. Sneed was still telling me about his symptoms: "There are no specific worsening or relieving factors. The discomfort would start suddenly without any warning." I noticed he appeared to be underweight. I glanced at the weight recorded by the nurse: 123 pounds, height 5'8". He had symmetrical wasting of both temporalis muscles. His sclerae were pearly white, and he had some angular stomatitis. I also detected some atrophy of the thenar and hypothenar eminences in both hands. "Have you lost any weight recently?" I asked him. "My weight has been fairly steady for the past few months, although I weighed 162 pounds before retiring," he answered. Probable malnutrition, I thought, as I was mentally going over the list of differential diagnosis for weight loss. "Tell me a little bit more about yourself," I said.

He had retired from the police force about two years ago. He was planning to spend some time visiting his children in New Zealand and touring that country, Australia, and the South Pacific Islands; but his wife died tragically in a car crash and he found out that his savings had collapsed to such an extent that he could no longer afford the trip. "Besides," he confessed, "I wouldn't want to go without my wife, even though the children insist that I visit them." The shrill ring of the phone on the desk startled him.

"Dr. H, you are running almost two hours behind schedule, and you still have six more patients to see," the office manager said when I picked up the phone, "and it's Friday afternoon!" I really did not need to be reminded. "Yes, I know, I'll do my very best to expedite the process," I answered almost automatically. Earlier that day I had spent much longer than I anticipated in the hospital. I was standing in for one of my colleagues and was late getting to the office.

"I don't want to take any more of your time, Doctor," Mr. Sneed said firmly as he stood up and offered me his hand to shake. "Nonsense," I replied. "We need to find out exactly what the problem is." But he had reached the door.

"My problems are only minor," he replied. "I am sure everything will be alright," he continued in a low voice as if talking to himself. "Besides," he said more loudly, "I have had all sorts of tests, as I am sure you have seen. Everything is normal. You have been very kind to me, Doctor. Thank you." He opened the door. "Please make sure to come back next week if you don't feel better," I mentioned hurriedly, but somewhat pleased that I had one less patient to see. "Of course, Doctor. Thank you. Have a great weekend," he said as he closed the door behind him.

Monday morning I learned that he had committed suicide during the weekend.

Editor

Please see "A Review of Postpartum Depression for the Primary Care Physician" on page 162 of this issue.

Copyright [c] 2004 by The Southern Medical Association 0038-4348/04/9702-0117

Ronald C. Hamdy, MD, FRCP, FACP