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Introspections   |    
Scaling Down
Mary V. Seeman, M.D.
Am J Psychiatry 2003;160:847-849. doi:10.1176/appi.ajp.160.5.847
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There is a saying among aging psychiatrists: "I didn’t start out as a geriatric psychiatrist [subspecializing in psychiatric problems of the elderly], but I have become one [having grown old and my patients having grown old with me]." As a psychiatrist who is aging fast, I see fewer patients than I once did—one form of downsizing—but age sizes you down in many more ways than this.

One of my patients, now 82, wants me to call her Kit. From someone with an originally long name who used to live in very grand style, Kit has changed into a frail person with a tiny name who lives in a miniature apartment in a home for seniors.

She was 40 when I first met her. Katherine Esterhazy (not her real name) was a well-known hostess then, living in a suburban mansion. A large woman, she and her husband could not sit in my office without knocking knees when they came for their first consultation. It was 1962, and my suite was a windowless cubicle on the sixth floor of a wing of the Toronto Western Hospital on Bathhurst Street in downtown Toronto. The desk was in the corner and, with the third chair moved in to accommodate the husband, the door did not close. Katherine would not have stood for it—the shabby room, the smallness of it, my very evident junior status—if it weren’t for the fact that she was depressed.

She had, the husband said, hardly spoken for days, hardly eaten. She had a psychiatrist, but he was at his wits’ end, having given her a double course of electroshock treatments to no avail. The reason Katherine was referred to me was because I was new in Toronto and not likely yet to know anyone in her extensive social circle. And my husband was a psychopharmacologist so, just maybe, I might have advance knowledge of some new and potent drug combination that could restore her normal vitality. I did suggest something relatively new at the time: tranylcypromine sulfate, a monoamine oxidase inhibitor that allowed more monoamine chemicals like dopamine and adrenaline and serotonin to get through neural synapses and activate nerve networks. Tranylcypromine, perhaps because the time was right for Katherine to recover, did the trick. Within 3 days, she was well.

My services would no longer be required, her husband called to say. As a thank you and goodbye, a mammoth poinsettia was delivered at Christmas, too large to fit into my office. Under normal circumstances, Katherine and her husband would never have come to see me again. Her physicians, as I was to find out, were all wealthy, famous, with large downtown offices, expensive furniture, Group of Seven paintings on the wall. Ten years later, however, I received another call from the husband; Katherine was again unwell because the pill that had been her savior all these years had been taken off the market. In combination with tyramine—a component of certain food stuffs—this pill made your blood pressure rise, and deaths from stroke had been attributed to it. Her psychiatrist had tried other tablets. Nothing worked.

Mr. and Mrs. Esterhazy came to my office, a more spacious room now, in the Medical Building on Leonard Avenue, just across the street from the Toronto Western. No Group of Seven painters on the walls but some original look-alikes, comfortable sofas, a receptionist to welcome you, and a place to wait in comfort.

Katherine wasn’t talking, but her eyes appraised her surroundings. I was married to a pharmacologist, the husband said. Could I gain access to her miracle pill, maybe directly from the manufacturers? Maybe my husband could make it in his lab? They would pay. She could not live without it.

I managed to get her the pill. If she had taken it for 10 years without incident I didn’t see why she couldn’t continue. I did caution her about what she ate and told her to have her blood pressure checked should she get a headache. And this time I wanted to follow her myself. I couldn’t prescribe a somewhat risky drug without seeing her, I said.

Their children had moved out, and now Katherine and her husband lived in a two-floor condominium apartment in Forest Hill, a smart section of Toronto. She continued her busy whirl of entertaining. Her husband, now retired, catered to her many whims. In contrast to my own nose-to-the-grindstone routine, her life was grand—many friends, many lovers, many possessions, many travels.

Of course, that was her exterior life. Inside, she was tormented by memories of a sickly childhood, a father who killed himself, a stepfather who maltreated her, a mother who failed to give credit where credit was due, a stunted education, an annulled first marriage. She had the strength of personality to overcome what would have been dead ends for others. Nothing stopped Katherine. She married outside her faith and thumbed her nose at those who looked down theirs at her. She nursed her mother and stepfather as they became infirm, forgiving them the past. She somehow lived through further suicides in her family. A family who suicides was the secret burden she bore.

Meantime, I moved from the Western to the Clarke Institute, a step upward in my professional life. In charge of a small unit, I was given a corner office with large windows on two sides and my own thermostat to control the office environment.

The Esterhazys moved to a one-level condo because Mr. Esterhazy was having some trouble walking. He still occasionally accompanied his wife to see me, but less. She had no more depressions as long as she took her pills, now commercially available again. We tried twice to stop them, and each time she retired to her bed, her head under the covers. We resolved not to try it again.

Katherine’s husband was considerably older than she was, and it was inevitable that he would die first. He went suddenly and left her totally devastated. For all her outside interests, he was the rock in her life and without him life became shaky. Her children, who had never seen below the surface to the person she was, had been attached mainly to their father and stopped calling.

Kate (she had never liked Katherine, she told me; it had been her husband’s name for her) couldn’t afford the large condo by herself, so she arranged to move to a smaller one. Even renting extra locker space, Kate had too many possessions to fit into her space. She began to have private sales—selling off her jewelry collection. As she was scaling down, I was selected to be Head of Psychiatry at Mt. Sinai Hospital, Toronto, a prestigious posting for me. A new office was specially constructed with built-in bookcases and a stereo sound system and very expensive furniture. I had a magnificent view of University Avenue when the Pope came to visit Toronto.

Newer drugs for depression had come on the market, and I suggested we try these rather than tranylcypromine. Kate had gotten the occasional high blood pressure headache, having eaten the wrong food by mistake now that her husband was no longer cooking for her. We tried three new drugs as they came on the market; each time, Kate relapsed and I had to arrange for special nurses around the clock. Back on a regimen of tranylcypromine, she recovered.

My term at Mt. Sinai ended, and I returned to the Clarke Institute, no longer head of anything. My office was not so luxurious as the one at Mt. Sinai. Kate didn’t like it. It didn’t, she said, fit my "status quo." She was going through very rough patches, especially with her children. She was trying valiantly to win them back. When it didn’t work, she despaired. Twice she attempted to take her life and was hospitalized at the Clarke, which by then had merged with three other sites and changed its name to the Centre for Addiction and Mental Health. The Centre morphed into a giant complex, and we were both lost within it—Kate’s hospital room was shared with two other patients; my office was partitioned into two to make way for new staff.

I turned 65, and someone younger took over my office. I moved to a smaller room with no receptionist and no waiting area for my patients. I had somehow managed to become a geriatric psychiatrist. I was even put on the Council of the International College of Geriatric Psychoneuropharmacology, without qualifications of any sort other than my age.

Kit (the name she now preferred) and her children resolved their differences. She had lost all her money through foolish investments, but the children chipped in and arranged for an apartment in a very posh seniors’ residence. So Kit, at 82, lives in tight but elegant quarters. And I, at 70, practice psychiatry in a very cramped office. I can get three straight-backed chairs into the room and still close the door, but I have accumulated so many memories and disheveled feelings over the years that I sometimes feel as if I cannot breathe.

Every night before Kit goes to bed, she counts out her tranylcypromine pills to take the next day. The pills and her faith in them keep her healthy although grumpy, often tearful, often lonely, often frightened. Her faith in me keeps me coming into work each morning, often tired and achy, sometimes trying unsuccessfully to remember the comforting word I want to be able to say.

My room is smaller. My capacity to retain things in memory has grown smaller too. The reservoir of wise counsel from which I try to draw is dwindling. The paradox for Kit is that now, as her need grows, the person she most relies on is scaling down.

Address reprint requests to Dr. Seeman, Department of Psychiatry, University of Toronto, 250 College St., Toronto, Ont., Canada M5T 1R8; mary.seeman@utoronto.ca (e-mail).

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