After bringing Julia to the ER, her doctor, alarmed by Julia's worsening condition, contacted a psychiatrist at the hospital and arranged an appointment for the following week. Hearing about Julia's veiled threat of self-harm, the psychiatrist had called the ER before I arrived to do the evaluation and left a message saying he felt that the patient should be admitted to a psychiatric unit.
Julia was immediately and fully responsive to the questions I asked. Though occasionally tearful, she seemed happy to be talking to someone. She was obviously frightened about her situation and was trying hard to rein in her emotions. Julia was not sure what was happening to her, and it soon became evident that the anxiety associated with this confusion was the acute component of her yearlong mood disturbance.
I was surprised when Julia let it be known, almost incidentally, that she felt guilty about her grandfather's death. She was the last person to see him before he died, and a cousin was miffed that she had not been contacted so she, too, could have been present. That Julia could be made to feel guilty for such an "infraction," particularly considering how much time she spent with each grandparent during their final illnesses, shows how psychologically vulnerable this woman was. The guilt her cousin put on her was clearly a factor in this case of complicated bereavement.
I reminded Julia that living to age 89 is a privilege given to few. As I said this, a part of her burden seemed to lift. Her affect brightened through the interview, and she was smiling near the end. She told me she was grateful that I was talking to her about her grandparents and how she felt about them. I explained that fluoxetine(Drug information on fluoxetine) might calm her down (and/or give her a "boost"), but it could not resolve the issues created by her loss or neutralize the guilt she was feeling.
I still had to find out what Julia meant when she said, "I want out," the statement that got her to the ER and set the stage for our interview. At first, Julia said she did not know what these words meant. She acknowledged being confused and overwhelmed by her feelings. I asked if, during the last month, as her depression deepened, she had ever thought of doing anything specific that would threaten her life. No, she said, emphatically. She denied ever trying to harm herself in the past. So what did Julia mean by wanting "out?" What did she want "out" of? Not life itself, apparently.
Like so many patients I have evaluated in the ER who said "I want out" and "I don't want to be here anymore," I believe Julia wanted "out" of the intense emotional pain that depression and guilt were causing her. Julia was confused and hurting, but she was not hopeless and despairing. We came to a shared understanding that she was not likely to harm herself.
Before discharging her from the ER, I needed to know how Julia saw herself getting through the next few days. She was anticipating a restless night or two, with some floor-walking to offset her nervous energy. Julia wanted a week off from work, away from the stress of her job. "I need someone to talk to," she said with conviction. "You have been very helpful." I took her words to mean that she had come to implicitly recognize a psychodynamic reason for her pain and the need for psychotherapy.
Just to get her reaction, I asked if Julia felt a hospitalization would help her. No, she said, citing among other reasons her reluctance to be confined to small spaces, like a hospital room. I was convinced that she would not benefit from being admitted and most likely would have her recovery slowed by this kind of confinement. Her parents felt it was safe for her to go home. Her father agreed to take a few days off from work to be with her. Her doctor agreed that she could be monitored as an outpatient.The Meaning of Self-Injury