Like many kids of the boomer TV generation of the nineteen-sixties, my first exposure to the great works of western civilization was by watching Bugs Bunny cartoons. Who hasn’t enjoyed the classics interpreted by Looney Tunes? Whether it was first hearing Rossini’s Barber of Seville, or Bizet’s Carmen, we relied on cartoon characters to be our cultural guides.
I remember one cartoon where Daffy Duck played Hamlet in the iconic “To be or not to be” scene, followed by Elmer Fudd’s answering shotgun blast. When the smoke cleared, Daffy’s face was blackened, his frilly collar was opened like burst barrel staves. His bill was blown backward. It was hilarious! “Shoot the Duck! Shoot the Duck!” Cartoon violence and an education! We had it good.
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Of course, when I was confronted with the consequences of a real-life shotgun injury as an anesthesia resident on the trauma ICU rotation at Seattle’s Harborview Hospital, it wasn’t so funny. A teenager in some particularly dark moment in his young life had decided to just end it.
He managed to position the barrel of the gun so that it aimed just under his chin, the cold steel pushing into the soft skin below the mandible. I imagined he used his toes to pull the trigger. Or he had it rigged somehow that he could fire it with a stick.
Needless to say, he must have given it some thought – but clearly not enough. When it fired, the shotgun kicked. He survived the blast of buckshot that blew off his jaw, his tongue, and the entire front of his face. It left him speechless, sightless, and grotesque – but his brain and dark suicidal thoughts were intact.
I spent the better part of four weeks in a cold and wet Seattle winter on my trauma rotation rounding on that boy in the ICU and after on the ward. My job as the resident on the service was to gather and report the results of all the daily lab tests in order to track his condition. “What is his blood count today, Dr. Swisher? What is his acid-base status? Are his electrolytes normalizing?”
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I learned about a condition known as SIADH, or “Syndrome of Inappropriate Antidiuretic Hormone” secretion, that can occur after a concussive blow to the head. Serum levels of the electrolyte sodium go out of whack. When the level gets too low it can be lethal.
So, I was a meticulous record keeper. I was diligent in following every drop of fluid and electrolyte that went into his veins and later through the feeding tube that snaked down the hole that used to be his nose, into his stomach.
I learned a great deal of physiology and medicine from taking care of him. I still remember my feelings of pride and competence after replacing an infected central line. Or when working inches away from him with surgical magnifying loupes, carefully debriding the damaged flesh that used to be his face. I did this every day for a month. To me, it was the ultimate doctor-patient relationship. It was practically intimate.
But many years later, when I think back to him lying alone in his dark, gloomy corner room in Harborview hospital in the thick of that cloudy, cold, and wet Seattle winter, unbidden and intrusive questions well up from a deep place in my mind.
Did anyone know how troubled and alone he felt in the months and days leading up to his attempt to abruptly and messily end his existence? Who were his friends? What was his childhood like? Most importantly, who was he?
At the time I had neither the maturity nor the courage to ask these questions myself. It is to my regret and shame that I don’t have a single recollection of actually talking to him about things other than what I was about to do to his body – though I must have. I would like to think I did, and hope I did, but I am not so sure.
Although he could not speak, he could hear, and certainly was capable of listening. I am most afraid that even if I did try to carry on what would have been a one-sided conversation, it wasn’t about anything important, anything relevant.
And now, over twenty years later as a father with teenage boys of my own, I have so many questions and so few answers. Why did he feel that life at sixteen was no longer worth living? Did he have any idea what his actions would do to his parents? Was there not a single person in whom he could confide? I will never know what he might have said, and it still haunts me. I try to squeeze my memory like a dry sponge for clues.
He had a mother, but I barely remember her. I never once saw his father. She was a small, pale, quiet woman who sat in a chair just inside the door to the room but far from the bed of her son, afraid to venture any closer. It was as if he had a disease that she could catch.
She hardly spoke, and when she did it was only in reply and then in brief monotone whispers. She didn’t seem sad as much as burdened and defeated. Now she was facing a cruel and uncertain future that held in its grasp a blind, mute, and faceless son. How would she care for him, and in what way? I was certainly of no immediate help, and even less use to her in the long term, so I didn’t try.
Being an emotionally helpless resident on a trauma service confronting the problems of the world is hard. But being an isolated teenage boy is much harder. I remember that time in my life all too well. Emotions are intense but lack the substance of experience. The desire to act is strong but knowing which direction to go is nearly impossible.
I have read Hamlet many times now and have it practically memorized. Like Hamlet, I abruptly lost a father and then watched helplessly as my mother hastily re-married a man I did not trust. And, whom I also knew did not trust me.
As a teenager, I was dark and moody, and like Hamlet full of unrealized thoughts of revenge. After I first read the play in Mrs. Shepard’s high school English, I was struck dumb with self-recognition! I imagined myself confronting my father’s accusatory ghost on the ramparts of my suburban Long Island home. I desperately wanted to believe my stepfather had poured poison into my father’s ear, stealing my mother.
I secretly longed for vengeance but didn’t know how to act. I also suppose like many a depressed teenager, I morbidly fantasized about taking “…arms against a sea of troubles, and by opposing, end them”. But unlike my faceless patient at Harborview, I never would have actually tried.
And so, I have become the father now, a man tempered by time and experience. I am no longer filled with rage and passion but have settled into a comfortable and safe existence.
As many a parent who lives in this privileged corner of the world, I carefully watch my sons for signs of depression. When they seem down and alone, I really try to talk to them. Sometimes I am successful at getting through. But my fear is that many times I am not and they regard my counsel as irrelevant.
I cannot be like my father, like the absent elder King Hamlet, doomed to walk the night as a pale ghost commanding his son to take up the sword against an uncertain enemy. I am all too real and disappointingly human. I think I am more like Polonius, the foolish and bombastic father of Ophelia and Laertes, dispensing dim advice and watching from behind the curtains as the world and its intrigues unfold.
I originally published this story on my PokitDok blog back in 2012. I have thought about it many times since, for both personal and professional reasons. This young teenager attempted to erase himself and his own life and succeeded in quite literally erasing the most prominent part of his physical identity, his face.
His attempt led undoubtedly to a markedly different world of pain and suffering for himself and his family. It is not a story with a happy ending. Truth be told, I don’t know how the story ended, or if it even did, as I lost contact with him and his family after the conclusion of my Intensive Care rotation at Harborview Hospital in Seattle. I struggle still to this day, more than thirty years later, with unwelcome but persistent thoughts of guilt over what I did not, or could not do for him and his family.
One of the problems with medical training that is seldom discussed is that young physicians are often put into emotionally difficult situations for which they are ill-equipped to handle due to their lack of maturity and experience. I often wonder how I would have comported myself differently after having the experience of a long marriage, having raised three children to adulthood, having been diagnosed with a long-term moderately debilitating medical condition of my own.
Our perspectives change as we grow older. We watch our children go from babies to toddlers, to elementary school students, absorbing the world like a sponge. They become awkward adolescents, achingly aware that the world isn’t always a kind and magical place.
They encounter peer pressure, bullying, and an intense desire to fit in and to be socially accepted. And inexorably, they drift from the comfort and security of home and family, growing more distant and inscrutable.
They pass through tempestuous teenage years, finding their own place in the world. Their personalities harden, giving the first solid glimpse of who they will become as adults. They take risks and get knocked down. Hopefully, they get up and learn from their mistakes and misadventures.
They discover attraction, attachment, sex, and love, while we as parents watch, sometimes helplessly from the sidelines.
They frequently make errors in judgment that we see telegraphed from a mile away. And, yet we can often do little to stop the occasional emotional or physical carnage.
Yet through all this, they have moments I can only describe as divinity. They amaze us with their insight, talent, and acts of becoming. Every now and then, however, some don’t make it. It seems more and more a modern affliction that younger and younger adolescents see no way out and thoughts of self-harm, and even suicide, bubble to the surface from some deep well of sadness and despair
I come from a close family, that was supportive on the one hand and demanding on the other. My sister, brother, and I were always expected to do well academically and in life.
There wasn’t a lot of talk about emotions or happiness, or lack thereof. But we were mostly happy despite the devastating loss of our father at a very young age. Despite this, or maybe because of it, we survived and prospered.
None of us, however, had depression. True depression – the kind that is seemingly impossible to emerge from. I still watch my now-adult children very carefully as my concerns for them have deepened. Their problems are no longer childhood problems but are ones that adults face. Hence they are more complex and capable of leading toward paths of greater darkness and uncertainty.
This has been a hard year for young people at the very genesis of their adult lives. Early careers and nascent dreams have been upended. Critical socialization has been put on hold. In my children’s case, a Senior Year and college graduation simply vanished like smoke, the idea and promise of it tantalizingly real, yet unfulfilled.
My daughter and her friends drifted away from each other at one of the most important times of her life. My middle son’s dreams of returning to a job in Japan, after having studied there in college, were also dashed as travel was curtailed. And my eldest son, a world away living in Australia cannot visit home and we cannot visit him.
These problems, I realize, are not unique to me, and I am so thankful we are all healthy and have been spared the greater tragedies of COVID. However, there is a sadness I sense in all of us. So, again, feeling more like Polonius or Prufrock, I wait expectantly, but cautiously to see what the next year brings. I hope that equal measures of joy and fulfillment are waiting for all of us around the bend.
“Dr. Swisher’s powerful essay illustrates the profound impact our patients have on our lives, particularly early in our careers. I have been teaching narrative medicine to medical students at Georgetown Medical School for a number of years.
The young doctors-to-be in my classes often write about memorable encounters with patients. Nicole Boisvert’s “My First Patient, My First Death”, for example, describes her experience of being a medical student caring for a woman during her dying days. As is true of the young Dr. Swisher in this essay, she found she was not prepared to respond fully to her patient’s complex needs.
Anyone who follows the news has noticed what seems to be an epidemic of depression.  While rates may be on the rise, there is also a new willingness to discuss the issue more openly. In this way and others, depression and infertility have three things in common:
For some, a diagnosis of infertility and the ensuing treatment brings a chronic state of stress. This can lead to depression or make existing depression or anxiety worse.
Research suggests that the psychological symptoms of women facing infertility are similar to those facing other serious medical conditions, such as cancer. Depression is more likely among those facing infertility if any of the following situations apply:
Furthermore, the medications used to treat infertility and infertility treatment itself can be associated with emotional changes, including depression.
How can you tell if what you are feeling – emotionally and physically – is explained by the situational stress of dealing with infertility? Or whether it is time to seek help for depression? It may not be so easy to decide.
According to the Harvard Mental Health Letter from Harvard Medical School :
“Patients and clinicians may find it hard to figure out which reactions are psychological and which are caused by medications — yet identifying causes is essential for determining next steps.”
Stress and sadness are often part of coping with infertility because:
One question to ask is whether feelings of being sad and tearful are episodic and tied to specific events such as hormone treatment, a test result, or a friend’s pregnancy announcement. These feelings are important to acknowledge and should be addressed through counseling, a support group, and/or self-care.
Depression is different. It ranges from mild to major and may be recurrent. Mild depression symptoms include feeling tired and sad.
Common signs of moderate to major depression include some or all of the following :
A significant percentage of women of child-bearing age believe that there is an association between mental health and increased rates of infertility. In fact, in 2017 a women’s health company surveyed over 1000 women aged 25-33 who had a college education or advanced degree and earned over $50,000 per year. They found that over 70% of them believe that mental health problems (such as stress and anxiety) can have a negative impact on fertility even though it has not been proven.
More formal studies of the relationship between infertility and mental health, on the other hand, have yielded mixed results. For example, one large multi-center study evaluating the effects of depression and antidepressant use on non-IVF treatment outcomes found different results for men and women :
Depression may lead to lifestyle changes that can negatively affect the chances of becoming pregnant. The following have been found to have an impact on fertility:
Multiple studies have found that infertility in both women and men can increase stress, depression, and anxiety. Further, early pregnancy loss can lead to post-traumatic stress disorder (PTSD).
In addition, hormonal imbalances that cause infertility may also contribute to mood disorders including depression. Hormone therapy to treat infertility, treatment failure and the isolation associated with infertility can also lead to depression.
With depression, it might be tempting to self-medicate with junk food or alcohol or to counter poor sleep with more coffee. However, each of these responses makes the situation worse in terms of both fertility and depression. The good news, though, is that certain lifestyle changes can positively impact both fertility and depression.
Various studies show that a poor diet – including fast food or food high in sugar  – increases the risk of infertility in women, negatively impacts sperm counts , and is associated with higher rates of depression and anxiety .
At the same time, a healthy diet has been shown to have a positive effect: one study showed that women undergoing IVF have better pregnancy outcomes from eating a Mediterranean diet. Another suggested that men who eat healthily have better semen quality. Further, the relatively new field of nutritional psychiatry is finding positive results of a healthy diet on depression and anxiety
Further, there is evidence consuming excessive caffeine (the equivalent of more than five cups of coffee per day) can hamper your ability to get pregnant .
Excessive use of alcohol makes depressive symptoms worse . The literature on alcohol consumption is mixed. There is no question that excessive alcohol use during pregnancy is associated with an increased risk of adverse pregnancy outcomes, including fetal alcohol syndrome.
However, the literature examining whether alcohol use impacts female fertility is difficult to interpret because there has been little to no standardization of the amount of alcohol consumed . Some studies reporting no impact on fertility looked at consumption levels that many would consider modest (0-7 drinks per week). Daily drinking and binge drinking were not specifically called out.
Regardless of the impact on fertility, most experts recommend that women planning on getting pregnant should avoid the use of alcohol because of its adverse impacts on pregnancy outcomes.
In my practice, we recommend certain mind-body practices to help improve your chances of becoming pregnant and feeling less depressed. These include
Creative expression including expressive writing or journaling and art therapy may also help. While the effectiveness of each of these is supported by research, finding what works for you and what you’ll stick with is key.
If you’re experiencing any symptoms of a low mood or depression, talk to your infertility doctor. It may help your doctor diagnose your infertility and better manage your treatment and overall care.
You may have a hormonal imbalance that helps explain your infertility and depression. Or, if you’re taking fertility drugs – like synthetic estrogen – it may explain mood swings, anxiety and aggravate depression. Your specialist may be able to make changes in your medication to help, refer you to the appropriate fertility counselor or mental health professional. Or even suggest taking a short break from treatment.
There are multiple factors to consider in deciding treatment including the use of antidepressants:
Counseling, support groups, self-help resources, telephone-coaching groups, and family and friends may work for many. Others may benefit from an ongoing one-on-one therapeutic relationship with a licensed mental health provider.
Individuals that require prescription psychiatric medications will need to see a licensed physician. They should preferably be under the care of a psychiatrist with experience working with women who are undergoing fertility treatments as well as women who require psychiatric medications during pregnancy.
In general, the combination of medication and talk therapy (such as cognitive behavior therapy) is most effective for treating clinical depression and this combination may also enhance the chances of becoming pregnant.
Your infertility clinic may have mental health professionals on staff that can provide individual or group counseling. If not, your physician or clinic can likely provide a referral to mental health professionals that specialize in treating people facing infertility.
The Mental Health ProfessionalGroup of ASRM believes that mental health professionals with experience in infertility treatment can help a great deal on a range of issues including how to control stress, depression, and anxiety. [17[ Together, your fertility doctor and mental health professional can help determine which treatment(s) – especially if medication is indicated – are most effective and safe for your specific situation.
There’s no doubt that dealing with infertility or depression is a major challenge. Trying to cope with both – at once – can be overwhelming. Please remember that both are medical conditions that are not your fault and that treatment is available to help you build your family while addressing your depression.
Published Aug. 19, 2018. Updated by the author for republication on Feb. 17, 2021