I was called to the emergency room late one evening to evaluate a 50-year-old man who had taken an overdose of his antidepressant medications mirtazapine (Remeron) and trazodone (Desyrel). "Ed," who had diabetes, also claimed to have injected 170 units of short-acting, regular insulin (his daily dose was 15 units). He called his estranged wife and told her what he had done. She immediately phoned a man who lived in the house where her husband rented a room, and he dialed 911.
Ed was lying on a gurney, hooked up to intravenous lines delivering electrolytes and dextrose. His affect was flat: his face had no expression, his voice no modulation. He looked and sounded depressed and described himself as feeling very depressed. "I don't want to live" was his answer when I asked why he took the overdose.
The 15 mirtazapine and 25 trazodone tablets Ed took were not life-threatening. Without treatment, 170 units of insulin would kill someone with glucose initially in the normal range (60 mg/dL to 110 mg/dL). Ed told me he was taking the mirtazapine and trazodone as prescribed, but had stopped taking insulin several months earlier. Ironically, the resulting hyperglycemia had saved him. (His glucose level was 136 mg/dL in the ambulance, 90 mg/dL in the ER and 270 mg/dL after the first infusion of dextrose, given to counteract the insulin overdose.) Six hours after Ed reported taking the overdose he was lethargic, but knew who he was, where he was and the date; he gave adequate, if minimal, answers to all the questions I asked.
Five years earlier, after working there for 20 years, Ed had lost his job as vice president of operations for a company that made glass products. "I saw it coming," he told me. "They got someone to work cheaper." Ed had a degree in business from a prestigious university. Since being laid off, his life had been what he called a "slow slide downhill." He had held several jobs for short periods, but hadn't worked for two years. "I've lost everything," he reported without emotion; his losses included the respect of his family. He was living in a rented room, had no money in the bank and was nearing the end of his unemployment insurance.
Ed's appetite was good, and his weight had stayed constant, but he had not eaten in two days because he could not afford to buy food. He was sleeping well. (The normal appetite and sleep are unusual for someone reputedly so depressed.) Ed had been depressed for eight years before losing his job and saw "many doctors" during that time. Both parents, now deceased, were diagnosed with depression.
Eight months earlier, Ed had taken an overdose of 100 acetaminophen (Tylenol) tablets, intending, he said, to die. He did not go for medical treatment. Later, he told his estranged wife about the overdose. At her insistence, he signed himself into a psychiatric hospital, where he stayed for 30 days and received electroconvulsive therapy. Ed was convinced his depression was due to a "chemical imbalance" and that he could do nothing about it, despite being told by doctors at the hospital that this was not the case. He insisted that he had not benefited from his contact with any mental health care clinician. Mirtazapine and trazodone had not helped him; neither had ECT. Patients who believe their depression is biologically determined often experience at least a placebo effect with these interventions, but Ed did not.
Ed gave the distinct impression of being helpless and hopeless. His self-esteem was zero. When I asked if he could imagine what it would take to get beyond his depression, he told me with conviction that he did not know. He didn't seem bothered by his lack of an agenda for getting out of the hole he had dug for himself, or as he thought of it, the hole his "chemical imbalance" had dug for him. He appeared totally passive with respect to his situation. "I'm not ready to get another job," he assured me.
