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Yui Okamura

Yui Okamura was born in Tokyo and raised in Honolulu. She attended DePaul University majoring in Health Sciences. In 2008 her family was hit hard by the recession, and she dropped out of school before finishing her undergraduate degree. She supported her family through 2010 until embarking on a 3-month backpacking trip in South America. There, she met a group of Physician Assistants providing care to rural areas of Ecuador. Yui immediately knew she had found her calling in life. After graduation, she intends to pursue Family Medicine, and head back to South America to pursue her passion of caring for underserved populations.

Essay: Resiliency

“I just never thought of myself as depressed. I’ve never been depressed. I think I’m just anxious. Can’t you give me medications to treat the anxiety?”

Mrs. Potter was sitting on the edge of her chair, leaning slightly forward and avoiding eye contact. She was a small-framed Caucasian woman in her late 50’s, dressed in street clothes: a black turtleneck sweater, black slacks, long black dress socks, and simple black loafers. She was wearing a pair of thick white wool gloves despite the warm temperature in the interview room. It became obvious very quickly why she was wearing them; she was very fidgety throughout the 30-minute interview and was unable to stop herself from rubbing her hands together nervously. Prior to the interview, the nurse had reported that the patient’s hands had been rubbed raw, to the point that she had open lesions on the surface of both palms.

There were 4 of us in the small interview room. Dr. Weasley, our attending physician, was sitting directly across from the patient in another chair about 5 feet away. Minerva, a third-year medical student and I, a second-year PA student, were sitting between the patient and Dr. Weasley, forming a circle. 

We had just finished asking Mrs. Potter a series of questions designed to evaluate whether the patient met the diagnostic criteria for major depressive disorder. Based on her answers, she met the full criteria for a major depressive episode with severe anxious distress.  

As the psychiatrist in charge of the unit, Dr. Weasley had been called in for a special consult by the admitting physician, Dr. Granger. Despite his best efforts, Dr. Granger had not been able to convince Mrs. Potter that electroconvulsive therapy was the best treatment modality for her. 

Electroconvulsive therapy, often referred to as ECT, involves the use of electrical currents passed into the brain through electrodes. To minimize discomfort, general anesthetic and muscle relaxant medications are given intravenously prior to the administration of the electrical currents. While the exact mechanism of how it works in treating depression is unknown, many studies have shown that it causes an increase in levels of dopamine, serotonin, and norepinephrine. Other changes in brain activity have been documented, such as increases in endorphins and other hormones, as well as changes in signaling and neuronal function. In short, it is a medically induced seizure that “resets” the brain. 

“I have been practicing for over 30 years, helping people like you who are struggling with these kinds of problems. There is no doubt in my mind that this is severe depression. I strongly suspect that your anxiety is stemming from the depression. Anxiety that stems from depression, that makes you unable to do things like drive or go out to the grocery store due to incapacitating fear that something bad will happen, is often unlikely to respond well to anti-anxiety medications alone.” Dr. Weasley spoke slowly and softly, matching his cadence and tone to the patient’s. 

Dr. Weasley paused for a long moment and waited until the patient made eye contact with him, and then delivered his closing statement, deliberately emphasizing key words: “I strongly recommend that you undergo ECT, and to start as soon as possible. It has been proven to be the most effective method for treating severe depression such as yours.”

It was nearing 11 o’clock, and Dr. Weasley’s outpatient clinic was scheduled to begin soon. He apologized to Mrs. Potter and told her we had to end this conversation for now, but we could talk again later in the day if she would like to discuss further. She seemed reluctant to leave the room and took her time in getting up from her chair. She blurted out several new concerns on her way out of the room: that her insurance company would not pay for the treatment, that her husband would not agree to the treatment, and that she would not see clinical improvement with the ECT. We were unable to address her concerns at that time, but repeated that we would meet with her again later.

At 4 o’clock that afternoon, we met with Mrs. Potter again. This time, she stated that she was too afraid to leave her room, so the three of us filed in and stood awkwardly around her bed. She was sitting on the edge of her bed, leaning slightly forward, with her hands clasped together in her lap. She was making a concerted effort to stop herself from rubbing her hands. Periodically, she placed one or both of her hands underneath her, sitting on her hands to keep from rubbing them together.  

She stated that she had spoken to her husband and he had been supportive of her receiving ECT. For the next 20 minutes, we persuaded her to try to be optimistic about how it might help her. We explained repeatedly that she was in a state of severe depression, which interfered with her ability to make decisions and to think positively. We made every attempt to appeal to her self-declared “rational nature” by citing statistics and numbers about the benefits of the treatment that we had previously discussed. With this, we began to see her slowly come around to the idea - but it was obvious that she was still struggling with the decision.

I never thought I would feel better, less anxious, and more like myself again.
Mrs. Potter

Dr. Weasley made a daring proposal. “What if I put in the order for the ECT for you for tomorrow morning, so that we can save a spot for you? If you decide in the morning that you don’t want to go through with it, you have that right and no one will force you to go downstairs for the treatment against your will. But if we don’t put in the order, and you happen to decide that you would like to try it, it may be too late to get you in for a treatment tomorrow - in which case you will have no choice but to wait until Monday. I suspect that waiting over the weekend will cause you to spend more time worrying about it and waffling back and forth. I will put in the order, and you can decide in the morning whether you want to go through with it. How does that sound?”

Surprisingly, she agreed to the proposal. We ended the meeting with her and returned to the nursing station to enter the order. We went on with the rest of our day, checked in with our other patients on the floor and completed various tasks and responsibilities. Minerva and I were dismissed after we completed our notes, and we each headed home. 

The following morning, I arrived at the unit a little before 8:00. I logged in to my computer and found that Mrs. Potter had undergone ECT at 6:00. When Minerva arrived, the first thing I blurted out was, “She did it!” We exchanged high-fives, both pleasantly surprised that she had gone through with it. We agreed to check in with Mrs. Potter together after we completed our tasks. 

We began pre-rounding on our patients for the day. After our attendings and residents arrived, we rounded with them again. We were assigned to make the necessary phone calls to family members and social workers for collateral information, updates, and coordination of care. As it turned out, the rest of the morning somehow got away from us and by the time we finished all our responsibilities, we both needed to leave to head to our respective afternoon outpatient clinics. We were both disappointed that we couldn’t check in with her, but resigned ourselves to trying again on Monday when we returned from the weekend. 

The following Monday afternoon, we were finally able to take a moment to see Mrs. Potter. She had completed her second ECT session that morning. She was seen walking in the hallway, which was already an improvement, given that the last time we saw her before she started ECT she was so anxious that she could barely leave her room. We asked her a few questions about her mood and her thoughts on her ongoing ECT. She described her mood as “better” and admitted that the actual experience of ECT had been a lot less distressing than she had expected. We talked about the difference between the public’s perception of ECT from popular 1980’s films and the reality of ECT as it is performed now. 

I noticed she was making more eye contact and that her psychomotor agitation had improved. She was less fidgety in her chair and her legs were calm and still, no longer bouncing up and down rapidly. She was still wearing her wool gloves, but she kept her arms crossed in front of her and was not attempting to move her hands. We thanked her for updating us on her progress and parted ways.

A week later, I was going about my usual pre-rounds in the morning when I passed by Mrs. Potter in the hall. To my surprise, she gave me a small smile and wave before she shyly turned her face down to her chest. I made a mental note to check in on her later when I had some time. Later that afternoon, I found her in the day room playing cards with a couple of other patients. I entered the room quietly and took a seat a few feet away from the group and planned on waiting for an opportunity to speak with her. I noticed immediately that she was no longer wearing her gloves. Before long, she looked up and saw me. I smiled at her and gently asked if she wouldn’t mind chatting with me for a couple of minutes. She agreed and followed me out of the day room, down the hall, and into an interview room. 

This time, she was even less restricted in her affect and speech. Her amount and quality of eye contact was markedly improved, and she even smiled a few times. When she shared with me that she was feeling so much better after 5 ECT treatments, I dared to ask about her gloves. I felt a large grin spread across my face as she proudly told me that she just stopped wearing them a couple of hours ago, as she had not had an urge to rub her hands in several days. 

I thanked her profusely for sharing her experience with me and confessed to her that I had become emotionally invested in her success. I explained to her that I would be honored if she would allow me to write about her case to let others know about her battle with depression and, more importantly, her path to recovery.

She looked me steadily in the eye and said, “I am so grateful to you and all the nurses and doctors and everyone here. I never thought I would feel better, less anxious, and more like myself again. It is because of you all that I was able to face my fear of ECT and overcome my paralyzing anxiety and depression. Of course I will let you share my story.” 

She told me that her treatment team had recommended a total of 10 inpatient ECT sessions, after which she would get discharged and continue maintenance ECT every 2-4 weeks as an outpatient. The frequency of maintenance treatments would depend largely on how well she readjusted to her daily life once she returned home. She acknowledged that she still had a ways to go in terms of getting back to her normal self, but the difference now was that she truly believed she could get there with the help of ECT, psychotherapy, and medications. At the end of our conversation, I shared a little about my personal struggles with depression and anxiety. I expressed my deep respect and admiration for her courage in seeking help and appropriate treatment during such a difficult time. 

Mrs. Potter was discharged from the hospital two days later. Although I regretted that I didn’t get a chance to say goodbye to her, I found comfort in the fact that she was well enough to go home and that she would give herself the best opportunity to adjust back to her normal life.