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Dealing with Emotional Pain


“Pharmacological stoicism.” Such was the phrase coined by Dr. Peter Kramer in his ground breaking book “Listening to Prozac.” I remember when I read this book in the 90’s, it reshaped how I view use of medication to alleviate emotional pain. This kind of stoicism is endemic in geriatric medicine.

According to research published recently in the Journal of American Medical Association, not only do physicians under prescribe for pain, 50 percent of nurses under-administer the pain medication once it is ordered.  This aversion to treating physical pain carries over in spades where the treatment of emotional pain is concerned.

Many doctors have a hard time realizing just how painful it is to be anxious and depressed.  I guess they’ve never been 80 and severely infirm and humiliatingly dependent on near strangers for even the most basic and private personal needs, absent caring family and with only death to look forward to.

One such physician I work with was asked for something to help a patient who was so anxious and depressed she pulled huge clumps of hair out of her head and picked at her skin until it bled.   This doctor didn’t want to prescribe what had been suggested for fear of over-sedation, so instead she prescribed Buspar, a less effective but routine anti-anxiety medication.

That might’ve been a good choice – but the problem was, she only gave us six.  This particular medication is not given on an as-needed basis (“prn”) but routinely, in order to build up a therapeutic blood level. Six was next to useless.

When I called her again, she was out of town and the on-call doctor returned the call. He ordered not only the anti-anxiety drug Ativan on a prn basis (to avoid over-sedation) but a routine medication to address the self-mutilating behaviors.  He made a decisive move to help a woman who was literally tearing herself apart. The primary physician may not enthusiastic about this when she returns, but it’s hard to argue with success: our patient is no longer suffering. She is much calmer now and not so miserable in her own skin.

Of course, I don’t want to see anyone over-sedated, especially if only to make life easier for someone else. Such a thing is abhorrent and rightly called patient abuse. Stringent state and federal regulations of all psychoactive drugs are aimed at prevented misuse in this way.  But refusing to acknowledge and treat the depressive ravages of the multiple losses typically faced by the elderly is no answer either. There’s a good argument to be made that turning a deaf ear and blind eye to a patient’s mental distress is equally as harmful and unethical as over-sedation.

Depression is the number one under-treated illness in the geriatric population. Unlike the profile of diseases that go along with aging, it does not show up on lab tests, or EKGs. It is silent and invisible except for its effects.
If in doubt, go to your nearest nursing home or assisted-living facility and look around.

People slumped in wheelchairs seeking the solace of sleep, line the halls in even the best homes. Pale and withered men and women trying very hard to be brave walk around gingerly, afraid of falling. Many more give up walking about the same time they give up caring. Some bear their inner storms in silence while some cry and some literally scream for help.

Those are the ones the staff learns to tune out.

What’s not to be depressed about? It is grueling business getting old and arthritis, congestive heart failure, diabetes, chronic obstructive pulmonary disease, kidney failure and pressure sores from bad circulation are not even the worst of it.

The unrelenting deterioration of the physical body is insult enough to make anyone despondent but the real traumas are those inflicted on the spirit by bruising emotional losses peculiar to old age: loss of spouse, family members, friends, home, independence and self-esteem.

The cumulative stress of a lifetime compounded by the rapid devastations of old age can crystalize into acute emotional distress. Because of decreased levels of serotonin and other neurotransmitters vital to mental and emotional balance, the burdens of life formerly borne with resilience and resolve can in the twilight years become completely overwhelming.

If our culture is notoriously stoic when it comes to physical pain, it is positively sclerotic when dealing with emotional pain.

Improved quality of life can be achieved for the elderly through a judicious, compassionate use of medications. When we have the means to ease their suffering, even just a little, it is more than a crime to refuse to do so.


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