When Your Patient Is Stigma-Free - But the Family Isn’t

Last year in this blog I wrote a 3-part series on stigma in physicians and the many ways in which this force undermines the help-seeking and treatment process in symptomatic doctors. I want to turn now to the situation in which your patient is not hampered by stigmatizing fear and shame, but important loved ones are. Here is an example of stigma that is related to cultural tenets and fears in a family. This is the story of a third-year medical student:

Ms. Brown is a 23-year-old Afro-Caribbean medical student who came to me with a self-diagnosis of depression. She was indeed correct. She had just completed her clerkship in psychiatry and believed that her symptoms added up to a depressive illness. She had been experiencing a low mood every day for about 2 months, she had lost almost 15 pounds in the same time span, her energy was depleted. “I feel like an old woman. I can’t run anymore, only walk, and that even tires me out,” she said. She complained of trouble studying – both concentrating on the material and remembering it, and now she was awakening every morning at 4 AM and couldn’t get back to sleep. Her spirits lifted a bit as the day went on but she was weary again by late afternoon. She was not suicidal. She could not come up with a specific trigger but she had a milder episode in college after a breakup with her boyfriend. This resolved spontaneously over time. Both her mother and paternal grandmother suffered from depression. She was open to medication plus supportive psychotherapy.

I started her on an antidepressant, gave her a sample packet and booked to see her again in one week. She kept that appointment but told me that she took only one dose. She said her father, an internist, was “really upset – he doesn’t really trust psychiatrists, (and thinks) that all you guys do is medicate your patients, especially minority folks and that psychiatric medications are dangerous. He doesn’t want me to see you. He told me to give this more time and to return to Wednesday evening bible study.” She gave me permission to call him. I called his office and got put through to his “confidential voice mail.” I left a brief message introducing myself and why I was calling. I asked him to call me back so I could answer his questions and explain my treatment plan with his daughter. He didn’t. After 3 days, I tried one more time. This time I simply asked his receptionist to ask him to return my call and that it was personal. No call back. My patient cancelled her next visit. She did not return my call either.

This doctor-father’s worries are rooted in shameful American history — and they are not unfounded. Even today in many top-notch medical centers, there are bold examples of microinequities of care that occur with racial and ethnic minority patients.  I regret not being able to have a conversation with the father about his daughter and hopefully reassure him about fair and standard contemporary treatment of depression. I hope that his daughter did improve and will perhaps find a better fit for herself down the road — and someone less threatening for her father.

Here’s a second clinical vignette, on a man I treated a few years ago:

Dr. White was a 48-year-old nephrologist who had been my patient for about 7 years when he remarried. He was in good recovery from alcoholism and was no longer being monitored by his state physician health program. I was also treating him for a longstanding comorbid social anxiety disorder. He had been stable for some time on a low dose of an antidepressant medication that works well for this kind of anxiety disorder. His new wife, Dr. Stone, whom he met in AA, was also a physician. She was really upset about his being on meds. At first, he thought she was worried that he would develop a cross-tolerance/addiction even though I had never prescribed a habit-forming medication for him. They talked and talked about how much the medication helped him but she really persisted and wanted him to taper and stop the drug. He refused and this made her angry. A couple of weeks later, his prescription bottle went missing. He asked her if she saw it and she said yes, she had flushed the pills down the toilet. He asked her to accompany him to his next visit with me.

She was open and I met with the two of them together. I explained the rationale and argument for the medication, what Dr. White was like before the medication and now the after picture, his relief of anxiety symptoms and how cooperative he had been. I also told her that her husband had never required a higher dose. I added that he did have CBT (Cognitive Behavior Therapy) in the past, which also helped but did not fully eradicate his panicky feelings in social situations. I also told Dr. Stone that I saw this pharmacological treatment as an important feature of relapse prevention and this reduced the likelihood of her husband’s going back to drinking. She did not argue with any of this.

She asked if I could spend the remainder of the session with her alone. Dr. White was fine with this. Once we were alone, she told me a lot about herself. Her mother was severely addicted to barbiturates prescribed by her psychiatrist while Dr. Stone was growing up. Dr Stone’s efforts to confiscate her mom’s pills and toss them out were to no avail. Her mom’s doctor just kept prescribing more and more. Her mother was in and out of psychiatric units, including one where Dr. Stone went to medical school. She was deeply ashamed of her mother and was also very ashamed of her own diagnosis of alcoholism. I suggested psychotherapy to her and she was very open to this.

This story had a good outcome. Dr. Stone was willing to have a conjoint visit with her husband and me and was also open to hearing me out. I welcomed her “back story” because it explained so much about her fearful attitude toward her husband’s treatment. In the end, she got some much-needed psychotherapy and Dr. White was free to be my patient without interference from her.

Dr. Myers is Professor of Clinical Psychiatry and immediate past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, NY. He is the author of seven books the most recent of which are “Touched by Suicide: Hope and Healing After Loss” (with Carla Fine) and “The Physician as Patient: A Clinical Handbook for Mental Health Professionals” (with Glen Gabbard, MD). He is a specialist in physician health and has written extensively on that subject. Currently, Dr Myers serves on the Advisory Board to the Committee for Physician Health of the Medical Society of the State of New York. He is a recent past president (and emeritus board member) of the New York City Chapter of the American Foundation for Suicide Prevention.  

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.