Years ago, I was asked to consult on a patient who was admitted to the Coronary Care Unit. Mr. Y was in his late 60’s. He was observed to be experiencing fluctuations in his mental status with questionable orientation and memory functions since the time of admission to the hospital. In addition, he displayed profound melancholia, evidenced by tearfulness, forlorn demeanor, negative thoughts, and verbalization regarding a “lack of desire to continue living.” Although he was not actively suicidal, there was concern for his safety due to a slow and gradual physical and psychological deterioration that was reported by his wife. Upon meeting him in the Coronary Care Unit, he was observed to be underweight, frail, and with a weathered, beaten appearance.
During the political revolution in his country, Mr. Y was under severe stress and became significantly depressed due to the nature of threats and violence that he experienced. During that time, Mr. Y suffered his first heart attack. After his heart attack, he and his family migrated to the United States following threats from guerillas. He was a professional in his country, but had to resort to menial labor due to his lack of knowledge of the English language and an inability to obtain certification in his profession, as many immigrants have to do to survive (a topic that perhaps will be discussed in a future post).
One day, after being offended, ridiculed, and humiliated by his employer, Mr. Y’s depression worsened and he suffered his second heart attack. He was transported from his place of employment by EMS to our medical Emergency Room, and psychological consultation was requested due to obvious symptoms of stress and depression. He appeared paranoid and had lost the will to live. A premorbidly strong and powerful man, he sobbed during our first meeting as he related feeling a deep sense of shame. Mr. Y stated, “In my country I was a person; here I am told I am a stupid Indian.”
Since the mid-1970’s, it has been well documented that there is a clear connection between the role of emotional factors and the stimulation of the Autonomic Nervous System with the onset of myocardial infarction, ventricular tachycardia and fibrillation, and other cardiovascular and medical disorders. A study by Meyers and Dewar (1975) reported that 23 out of 100 patients experienced sudden cardiac death provoked by intense emotions and a major life stressor in the thirty minutes preceding death, and an additional 40 percent in the preceding 24 hours.
Similarly, a study by Greene (1974) demonstrated a high correlation between sudden cardiac death and depression (74 percent). The authors concluded that central nervous system activation and depression was being experienced at the time of the lethal cardiac event. Sudden death and myocardial infarction have also been associated with bereavement, alienation from one’s culture, loss of employment and depression, among multiple other factors. Scientific studies have also demonstrated a higher morbidity and mortality rate among persons who have had a heart attack, stroke, or cardiac arrhythmias and comorbid clinical depression.
It is thought that the high correlation between cardiovascular events and depression are not only due to environmental and psychological issues, but also due to neurobiological factors, i.e., the role of neurotransmitters, particularly serotonin, in modulating the release of platelets in the blood stream. Due to deficiencies in the availability and neurotransmission of serotonin during states of clinical depression, it is hypothesized that there is an increase in platelet activation, potentially resulting in subsequent heart attacks, strokes, and premature ventricular contractions (Morris, et. al, 1993; Fraser-Smith, et al, 1995; Laghrissi-Thode, 1997). Not only do people who suffer from depression suffer very unpleasant symptoms and emotional pain, but they are also at risk for the development of and/or exacerbation of a number of medical conditions, particularly if these individuals have a contributory medical history and/or are genetically predisposed.
Although I only met Mr. Y on one occasion, I was personally impacted by the heaviness that he carried, and his profound sadness and multiple losses that he had experienced in his life. Moreover, he was a strong and courageous man who fled his country and endured multiple sacrifices to provide a better life for his family. It was obvious that he loved his country, and that he had no greater wish than to return to his home. I never saw Mr. Y again. I went to see him the next day for a follow up visit and was informed by the nursing staff that he had died in the early morning hours. Mr. Y is finally home.
In his memory, our Medical Psychology Consultation Liaison team published a paper dedicated to him (Gonzalez, E.A., Natale, R.A., Pimentel, C. and Lane, R.C. (1999). The narcissistic injury and psychopathology of migration; The case of a Nicaraguan man. Journal of Contemporary Psychotherapy, Vol. 29, No., 3, pp 185-194.
For comments and questions regarding the evaluation and treatment of stress and depression at the Jackson Mental Health Hospital, please contact us at firstname.lastname@example.org.
Note: Patient information contained herein was extracted from above-cited journal article.