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.

New Dr. Margaret Cary‘s Review Notes appear at the end of the story.

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.

A suicidal teen

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?”

Related Content: Suicide in America: Understanding the What and Why

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.

Thinking back

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.

Intense emotions but lack of experience

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.

I am a father now

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.


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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.


Medical Reviewer Notes by Dr. Margaret Cary:

“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. 

Swisher describes feeling competent about the “nuts and bolts” of care (managing blood counts, acid-base status, and electrolytes). But in retrospect, he realizes that he may have fallen short when it came to caring for the whole person. In this case, a young teen who was speechless, sightless, and grotesque – but [whose] brain and dark suicidal thoughts were intact.”
 
He is correct when he writes 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 suspect we have all felt that at some time early in our training. Importantly, he makes a persuasive argument for providing support to young doctors and medical students as they grow into the skills needed to fully engage in the art of medicine. I wholeheartedly agree.

Anyone who follows the news has noticed what seems to be an epidemic of depression. [1] 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:

      • both are medical conditions
      • deserve to have treatment covered
      • more work remains to reduce the stigma of the condition

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.[2] Depression is more likely among those facing infertility if any of the following situations apply: 

      • They experienced depression before receiving their infertility diagnosis.
      • There is a family history of depression.
      • They lack a support network resulting in feelings of isolation.

Furthermore, the medications used to treat infertility and infertility treatment itself can be associated with emotional changes, including depression.

How can you tell the difference between sadness and depression in infertility patients?

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 [3]:

“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.”

–Sadness

Stress and sadness are often part of coping with infertility because:

      • dreams of a family are altered
      • the relationship with your partner may be tested
      • the medications required during treatment can play havoc with mood

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

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 [4]:

      • Sadness that persists, lasting for weeks or months
      • Feelings of hopelessness and helplessness
      • Frequent crying
      • Often feeling irritated or intolerant of others, especially people who you used to enjoy being around
      • Lack of motivation, struggling to get things done at work and/or home
      • Difficulty sleeping, either sleeping too much or insomnia
      • Problems with eating, overeating, or low appetite
      • Struggling with experiencing pleasure in life, including a lack of interest in sex
      • Frequent feelings of anxiety or worry
      • Thoughts of dying, self-harm, or suicide – seek help immediately!

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Does depression cause infertility?

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.[5]

–Formal studies have yielded mixed results

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 [6]:

  • Women with currently active major depression (MD) did not have lower pregnancy or live birth rates compared with women without MD
  • Male partners with current active major depression were less likely to achieve conception
  • The use of antidepressants by the mother was associated with an increased risk of miscarriage in the first trimester, particularly when the antidepressant was NOT an SSRI.

Lifestyle changes related to depression may impact fertility

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:

  • Appetite changes that lead to being over-or underweight 
  • Excessive alcohol consumption and/or smoking may start or increase with depression and anxiety. 
  • Depression-associated sleep disorders
  • Sleep disorders related to some infertility medications 

Does infertility increase the risk of depression?

Multiple studies have found that infertility in both women and men can increase stress, depression, and anxiety.[7] Further, early pregnancy loss can lead to post-traumatic stress disorder (PTSD).[8] 

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.

Lifestyle changes that make a difference

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.

–A healthy diet is important

Various studies show that a poor diet – including fast food or food high in sugar [9] – increases the risk of infertility in women, negatively impacts sperm counts [10], and is associated with higher rates of depression and anxiety [11]. 

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.[12] Another suggested that men who eat healthily have better semen quality.[13] 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 [14].

Alcohol use is counterproductive

Excessive use of alcohol makes depressive symptoms worse [15]. 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 [16]. 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.

–Mind-body practices are beneficial

In my practice, we recommend certain mind-body practices to help improve your chances of becoming pregnant and feeling less depressed. These include 

  • yoga
  • meditation 
  • guided imagery 
  • mindfulness exercise 
  • being in nature.

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.

Additional content from Dr. Adamson:
Opioids and Infertility – What You and Your Doctor Should Know
One Couple’s Journey on the Bumpy Road of Infertility

How to treat depression during infertility treatment

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.

–Mental health support options

There are multiple factors to consider in deciding treatment including the use of antidepressants:

  • history of depression;
  • whether it is recurrent and/or active;
  • severity (mild, moderate, or severe)
  • what other types of support have worked or failed
  • the risks of untreated psychiatric illness 
  • fetal exposure to psychiatric medication

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.

The bottom line

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.

References:

  1. Fact Sheets. Depression, World Health Organization (WHO), 2020 Jan. 30, https://www.who.int/news-room/fact-sheets/detail/depression. (Accessed 2/16/21)
  2. Domar A, Zuttermeister P, Freidman R. The psychological impact of infertility: a comparison with patients with other medical conditions, 1992, J Psychosom Obstet Gynecol, 14, suppl 45-52. https://pubmed.ncbi.nlm.nih.gov/8142988/
  3. Harvard Medical Letter. The psychological impact of infertility and its treatment, Harvard Mental Health Letter, Harvard Medical Publishing, Harvard Medical School, 2009 May. https://www.health.harvard.edu/newsletter_article/The-psychological-impact-of-infertility-and-its-treatment
  4. Gurevich R. Depression-related Infertility Causes and Treatment, VeryWellFamily 2020 Aug 3. https://www.verywellfamily.com/infertility-and-depression-101-1959977  (Accessed 2/16/21)
  5. Gresge G. This Is the Biggest Misconception that Millennial Women Believe about Infertility. 2017, Dec. 24, Brit+Co. https://www.brit.co/millennial-women-attitudes-toward-fertility-celmatix-survey/
  6. Evans-Hoeker E, Eisenberg E, Diamond M, et al. Major depression, antidepressant use, and male and female infertility, Fertility and Sterility, 2018 May. https://www.fertstert.org/action/showPdf?pii=S0015-0282%2818%2930029-3
  7. Harvard Health Publishing. The psychological impact of infertility and its treatment, Harvard Mental Health Letter, 2009 May. https://www.health.harvard.edu/newsletter_article/The-psychological-impact-of-infertility-and-its-treatment (Accessed 2/16/21)
  8. Farren J, Jalmbrant M, Falconieri N, et al. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study. Am J Obstet Gynecol, 2020 Apr. https://pubmed.ncbi.nlm.nih.gov/31953115/
  9. Boston University School of Medicine. One or more soda a day could decrease chances of getting pregnant.” ScienceDaily, 13 February 2018. https://www.sciencedaily.com/releases/2018/02/180213120426.htm
  10. BBC. Diets Linked to Low Sprem Counts, BBC News, March 12, 2012. https://www.bbc.com/news/health-17353804. Accessed 2/16/21
  11. Jacka F, Pasco J, Mykietun A, et as. Association of Western and Traditional Diets on Anxiety and Depression in Women, Am J Psychiatry Online, 2010 Mar. 1. https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2009.09060881
  12. European Society of Human Reproduction and Embryology. Mediterranean diet may help women receiving IVF achieve successful pregnancies. Science Daily, 2018 January 26 htpps://www.sciencedaily.com/releases/2018/01/180129223846.htm
  13. Efrat M, Stein A, Pinkas H, et al. Dietary patterns are positively associated with semen quality. Fertil. Steril., 2018 May. https://www.fertstert.org/action/showPdf?pii=S0015-0282%2818%2930010-4\
  14. European Society of Human Reproduction and Embryology. Five or more cups of coffee a day reduce the chance of IVF success by around 50 percent. Science Daily, 2012 July3. https://www.sciencedaily.com/releases/2012/07/120703120659.htm
  15. Godman H, Levine D. Is Alcohol a Depressant? US News and World Report, 2019 June 7. https://health.usnews.com/conditions/mental-health/depression/articles/is-alcohol-a-depressant\
  16. deAngelis C, Nardone A., Garifalos F, et al. Smoking, Alcohol and Drug Addiction and Female Fertility. Repro Biol Endocrinol. 2020 March 12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7069005/

Published Aug. 19, 2018. Updated by the author for republication on  Feb. 17, 2021