Sad Sam -Calm down?! Weren't you listening? I just told you that my son is going to kill himself! -I understand your feelings Mrs. Waters, but I need you to give me the exact words your son used. -He told me, "I'm tired of being drugged up and constantly seeing these doctors." He told me, "You're a grown woman, mother; and your happiness is completely independent of my life. I am not going to be here much longer and you need to deal with that fact." That's when I broke down. -And what of this "deal" you spoke about earlier? -I asked him to do me just one favor before he did anything rash. I begged with him to try just one more psychiatrist. He agreed, and I knew it was because he still cares for me, even though his face didn't show it. Do you think you can help him? -I can give you my word that every avenue, every possibility, will be looked into with the greatest care. With these words, I entered into the most trying, frustrating time of my life. To this day, not an hour goes by that I don't wonder if the decision I made was the correct one. By writing about this experience, I hope to answer these plaguing questions. When Samuel entered my office for the first time, he struck me as the stereotypical depressive you might see on a TNT movie of the week. Comfortably unkempt in a pair of jeans and a white T-shirt, this tall, lanky, pale character slowly glided across the room to the chair in front of my desk. Upon my asking, "How are you today Sam?" I was utterly shocked by the loud, confident, and somewhat wry reply: "I am stupendous today, and yourself?" Such lucid speech was quite contrasted to the typical, stop-and-go, under-the-breath replies I had been given by my other depressed patients. Seemingly, Sam lacked any type of anxiety; I knew this was going to be a unique case. I was then told about the beginning of Sam's plummet into depression. He pinpointed it to last year, the summer before freshmen year of college. Yet I noted that no particular stressful event had served as an impetus, prompting me to think that the disorder was more endogenous than reactive, but why then did the previous medications have no effect? A popular and athletic student in high school, he soon began to withdraw from both his friends and his beloved sports. The reason given: "They just weren't fun anymore." Small instances of indifference soon mushroomed into perpetual states of mind. Once idealistic and outspoken, Sam no longer felt the need to defend his beliefs-he didn't care about anything. Where once he would spend late nights with friends and girls, he increasingly decided to stay in and read. In my opinion, continual reading of pessimists like Sartre and Camus greatly contributed to Sam's negative cognitions. Eating became a task as opposed to a pleasure, and his once sculpted body deteriorated to the point where he could have became a Parisian supermodel. Most disturbing to friends and family alike, were the constant remarks about the meaninglessness of life and his suicidal ideations. Particularly upsetting, were the quixotic fantasies of suddenly running away. "I wouldn't mind homelessness or being in prison," he would say, "those lives aren't anymore meaningless than my current life." Despite such disheartening depictions of his life, Sam's life was completely free of distress. Though he saw friends less often, he would talk or visit if they initiated. Still close to his family, he continued to come home often to see his parents. Also, he was excelling in college. On the Global Assessment of Functioning, I noted only a slight impairment and gave him a rating of 75. But again, throughout all of these activities, an atmosphere of complete anhedonia remained. Though the behavior was not personally distressful, it caused a great deal of distress to those around him. Coupled with the problems of emotional and behavioral impairment, and behavior that was culturally atypical, Sam fit the DSM-IV definition of having a psychological disorder. Axis I is the axis for the clinical disorder. Dysthymia was quickly ruled out because of excessive suicidal thought and a lack of stress (Klein, Lewisohn, & Seely 1997). It was quite apparent that the diagnosis would be major depression. However, he was not quite as definitionally depressed as I had first suspected. He barely attained the label by demonstrating the minimum five of nine symptoms needed for the diagnosis. These five were: depressed mood most of the day, markedly diminished interest or pleasure in all, or almost all, activities, significant weight loss (when not dieting), feelings of worthlessness or excessive inappropriate feelings of guilt, and recurrent thoughts of death. Also, because of the weight loss and anhedonia, I considered listing the melancholic specifier, but Axis II was to more accurately account for these symptoms. Axis II accounts for personality disorders. Because of decreased desire for close relationships, preference for solitary activities, lack of pleasure from most activities, lack of close friends, indifference to praise or criticism, and emotional detachment, Sam fit the criteria for schizoid personality disorder. It is thus easily understood that personality may influence behavior, and is to be an important part of the therapeutic prognosis. Axis III deals with existing medical problems and was left unmarked for the still-healthy-but-rapidly-diminishing body of Sam. Axis IV lists the stress factors involved in Sam's life. Although this list would be lengthy for those closest to Sam, Sam could not think of anything that introduced stress into his life. Axis V offers a measure of functioning in the world and includes the aforementioned, particularly high score on the Global Assessment of Functioning. Given the diagnosis, I attempted to conjure up the treatment that would be most effective. First, I ruled out drug therapy as it had failed repeatedly in the past. Displaying an incredible amount of bad luck, Sam turned out to be one of the 48.5% of depressed outpatients not helped by Tricyclics, the 42.6% not helped by Monoamine oxidase inhibitors, and the 52.6% not helped by Selective serotonin reuptake inhibitors (Barlow 211). Also, the symptoms seemed to indicate a non-biochemical origin for the disorder. Each of the major depressive symptoms held, were cognitive. Other symptoms that would have indicated a biological imbalance-such as insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or energy loss nearly every day, and diminished ability to think or concentrate-were not present. Next, given his unstressful life and the caring natures of both family and friends, I decided that an interpersonal therapy would be of little help. It seemed that the disorder must stem from irrational beliefs and possibly negative associations within a broad range of social situations. Thus I determined that Cognitive Behavioral Therapy would be the most effective treatment. Prior to embarking upon the cognitive portion of therapy, my spirits were high as I thought of how scientific inquiry had shown cognitive therapy to be at least as effective as medications (Derubeis, Gelfond, Tong, & Simons, 1997) and better at preventing relapse (Evans et al., 1992). Typical irrational beliefs associated with depression are: a negative self-image, an external locus of control, and learned helplessness. However, as I soon discovered, Sam did not evince any of these characteristics. In fact, he was quite confident with himself. He felt in control of the events of his life and even realized that he had more control than most people did. Later, we did determine that Sam displayed signs of Beck's cognitive triad for depression-though this finding was of no help in the end. I attempted desperately to convince Sam that negative thinking is associated, and may actually cause depression (Bradley & Mathews 1988), and he did eventually concede to this point. But, he quickly retorted by telling me, "Before you said that irrational thought causes depression, now you say that it is negative thought. Negative thought is not necessarily irrational and I see no point in relinquishing a rational style of thought simply because it causes depression." Before this moment, I did that think it was possible to be rationally suicidal, but a comment later made by Sam definitively changed my mind. After I had asked a question that basically attempted to understand the rationale for his isolation and suicidal ideation, Sam replied, "The reason I don't like to interact often is because I don't want people to become attached to me. Suicide is morally impermissible when it causes excess grieving." Feeling somewhat disturbed by such bleak rationale, I decided to focus more on the behavioral aspects of Cognitive Behavioral Therapy. I had not completely lost hope at this point. With behavioral therapy, the most important component is to try to get the patient to engage in previously pleasurable activities (Shaw 1977), and I felt optimistic about the help this would give Sam. Also, many studies had shown that behavioral therapy is more effective than cognitive therapy with regards to major depression (Jacobson et. Al 1996) -You told me earlier that as recently as one year ago, you found pleasure in activities such as dating and lifting weights. Why don't you try these out again? -I have it doesn't do anything for me, I just get bored and feel like I am wasting my time. -Why would you think that you couldn't receive pleasure from something that has previously given you pleasure? -I used to get a kick out of climbing trees and eating glue, but that doesn't mean these activities would be pleasurable now. They just remind me of what a stupid little kid I was and make me more depressed. I'll even give you a more recent example, weight lifting. I tried to get back into to, to rediscover the pleasure I used to get from pushing myself into a new and more attractive body. But when I went to the gym, I looked at all the meatheads and got more depressed. I thought, "What kind of life would it be to live for such pointless things as dumbbells and biceps?" It's like this one time. I read an essay on laughter theory and then took a date to a comedy. I didn't laugh once, not because it wasn't funny, but because I was too busy thinking about why it was funny. And once you know why it's funny, it's not funny anymore-it just makes me sad to see everyone else laughing. I feel this way about most activities. What I'm saying is that these homework exercises you give me to get out of the house not only don't help my depression, they make it worse. Besides, I've studied this as well, and we both know that even if you do somehow cure me, there's an 80% chance of relapse (Judd, 1997; Keller, Lavori, et al., 1992), so what is the point? What could possibly be replied to such a charge? My most cherished therapies had utterly failed in the worse of all possible times. Soon after this, I received a phone call from Mrs. Walker. Hysterically, she told me of Sam's increased talk of death, his seemingly tying loose ends, and even parasuicidal behavior. While Sam was reaching for something in the cupboard, she had noticed something on his arm. After asking him to lift his sleeve, she saw an elaborate design made completely of scab. He nonchalantly responded that he was "just bored" and that "keloid looks cool." I took every word in, and attempted to abate her fears by saying I would figure something out in our therapy session the next day. However, for the first time in months, Sam failed to show up. Fearing the worse, I called the police. The police found Sam drunk at a local park, with a suicide letter ready in his pocket. He was immediately taken to the hospital where Mrs. Waters and I were already waiting. Preparing for our encounter with Sam, Mrs. Waters and I talked about our options. There was only one left it seemed, electroconvulsive therapy. Numerous studies had shown that for severe, suicidal depression, ECT is both safe and reasonably affective (Black, Winokur, & Nasrallah, 1987; Klerman 1988). Also, the possible melancholic specifier increases the expected efficacy of ECT (Crow et. Al, 1984, C.J. Robbins, Block, & Paselow, 1990). "Everything has failed," I started as we entered Sam's room, "the medications, cognitive therapy, behavior therapy, and you're still suicidal. Your mother and I have decided that ECT is the last option and it must be taken." When he refused to give consent, we had him drugged and performed the procedure anyway. After all, someone who is suicidal and would refuse a possible life saving treatment is obviously not capable of making his own informed decisions. After a few weeks of electroconvulsive therapy, Sam actually did start to improve. With much relief to Mrs. Waters and myself, Sam began living a normal life once again. He is now lifting weights multi-weekly, active in a few local organizations, and even dating a little. Solitary activities such as reading have been notably reduced. Prospects for Sam's future are at an all-time high, and it is all owed to ECT. Though ECT has been experimentally shown to be effective (Brandon et. Al, 1984; Fernandez, Levy, Lachar, & Small, 1995), little is known about why it is effective. Cases such as Sam's give us rarely seen insight into this mystery. Side effects of ECT-induced brain seizures include short-term memory loss and confusion, long-term memory loss, and structural and functional changes in the brain. With Sam, depression was not caused by stress, neurotransmitter problems, family problems, family history, nor irrational thought. It seems to have actually been caused by rational thought. Perhaps the brain damage and memory loss caused by the brain seizures hampered this ability enough to curtail its affects. We would thus conclude that by impairing Sam's cognitive abilities, we have saved him from depression and allowed him to live a happy and fulfilling life once again. However, is Sam truly happy, or does he merely not remember that he is sad? Does it matter? Works Cited American Psychiatric Association. (1994) Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author Barlow, D.H., & Durand, V.M. (1999). Abnormal Psychology. Pacific Grove: Brooks/Cole Publishing Company Derubeis, R.J., Gelfond, Tong, T.Z., & Simons, A.D. (1997) A mega-analysis of cognitive therapy versus pharmacology for severely depressed patients. Unpublished Manuscript Evans et al. (1992) Differential relapse following cognitive therapy, pharmacology, and combined cognitive-pharmacology for depression. Archives of General Psychiatry, 49, 802-808. Shaw, B.F. (1977) Comparison of cognitive therapy and behavior therapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 45, 543-551. Jacobson et. Al. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295-304.