Physical examination and investigations were unremarkable.
Impression
The impression was that Ms. A suffered from depression of moderate severity with somatic complaints, related to relationship problems with daughters, over a background of dysthymia, and prominent sleep disturbance.
Management
The treatment involved medication (mirtazapine and clonazepam for mood and insomnia); referral to psychologist for cognitive behavioral therapy (CBT) for depression and insomnia and referral to occupational therapist for daytime engagement and cognitive assessment.
Progress
Ms. A's mood improved quickly after admission. Mirtazapine was titrated to 30 mg nightly. Clonazepam 0.5 mg nightly was also given. Pregabalin was added for restless leg syndrome related to mirtazapine and clonazepam. Ms. A had a good response to mirtazapine and refused to switch to an alternative antidepressant. She enjoyed when her family visited her. Sleep improved from 3 to 5 hours per night with structured routine, good sleep hygiene, and medication.
Ms. A wanted to live in her hometown for a short while and wait there for a singleton public housing unit to become available. Ms. A felt that living separately would prevent any conflict developing with her daughter. She was encouraged to develop leisure activities and participate in social gatherings. During discussion on postdischarge life, she often claimed sleep was still suboptimal and requested further hospital stay.
After the first discharge from hospital, Ms. A had repeated admissions for suicidal thoughts when she was feeling that she was being abandoned by her family. She still had insomnia with poor sleep hygiene. She continued to lack any daytime engagement, and this was more so when grandchildren grew up and did not need much of her care.
Consultation
JM thanked the doctor for the full presentation, but in view of the limited information available for Ms. A's early life history, he asked the doctor to clarify if there were any more data about this important period in her life. The doctor responded that Ms. A was reluctant to talk about that period in her life. Ms. A remembered “repeated scolding” but denied any abuse—physical or sexual. Ms. A spent most of that time looking after the young “siblings” of that family. JM invited the doctor to give some more information about this woman's experience of living with this family, such as “what was it like being adopted?” The doctor clarified that her state was not one of adoption; she was expected to work for the family in return for meals and shelter. Later, the doctor explained that Ms. A had described her experience as a form of emotional “torture” and had explained that the “mother” treated her as a maid and not as a family member.
JM asked if this was slavery and the doctor responded that Ms. A perceived it this way. She further perceived that she lacked parental care and that her childhood was deprived. JM inquired if she was educated, and the doctor replied that she was not allowed to go to school, and the family did not spend any money on her education. JM asked about her status as a worker and if from the age of 1 she was an unpaid worker for this family and if the deprivation of education was common at that time in such villages in her home area. The doctor responded that she was an unpaid worker and the absence of education was common in many poor families at that time in similar villages.
JM asked the doctor to clarify what Ms. A's perception of growing up would be. Would she see herself as having a similar life experience as the other children in her “bought‐in” family? Did the other children receive education? The doctor responded that she would see herself as disadvantaged because the other children did receive education. Ms. A. often “grumbled” that her biological siblings received better care that she did. She knew who her biological family was. JM said, so she was aware that she was not the child of the family in which she had been sold. Yes, because she was in contact with her biological siblings. JM asked about her understanding of why she was sold and not any of the other children. Ms. A. did not have a clear idea of why that was the case. She attributed the sale to poverty and to the fact that her elder biological sibling was needed to look after the other children because the parents had to work to sustain the family.
JM summarized the predicament of Ms. A as that of someone whose life was far from ideal but not unique in that cultural setting. She lived with her daughter's family (not unusual in that culture), she had been divorced (not uncommon in today's city—or elsewhere), she remained in contact with her children, and she was unable to work (5 years from retirement age). Her situation could not completely explain her depression. Not many women in her situation suffer from recurrent depressive illnesses and gain hospital admissions because of suicidal ideation. One needs to look deeper and further to gain a genuine understanding of her depression. Another important feature of her condition is that Ms. A improves rather quickly after admission to hospital. She improves before any medication has time to cause a lift in mood.
JM inquired what the doctor's understanding of why Ms. A responds in this way to her predicament. The doctor replied that she has no role in her daughter's family. She did have a role when she was bringing up her children and her grandchildren; since she lost her job, she lost not only a role but also the social contact and she felt lonelier. JM replied that she had to contend not only with the absence of a role and of connections but also with the loss of them (role and connections) and that she was becoming more isolated and without a purpose in life. JM asked if her connections were related to her “feeling useful?” The doctor said yes.
JM noted that it seems that when she lived with her daughter, she was fulfilling a number of functions; she was useful and in return she had connections and a purpose in life. With the loss of these functions and connections, she not only feels redundant and isolated, but she is without a useful role and without meaningful connections. JM asked if she has any other connections, such as with friends. She is friendly with some neighbors with whom she plays cards sometimes, but this activity “bores” her at present and so, she does not seek their company as much. JM then stated so, she does not have any friends. The doctor replied, none at all. JM then said, and is this the reason why she is dreaming of returning to her hometown? Is she hoping that she will find some connection there? The doctor agreed with this. JM noted that her predicament is depressive; she has not managed the present transition in her life in a creative way and asked if she could have stayed with her daughter if she had managed the situation there more positively. The doctor said that it is common for grandmothers to stay with one of their children's families in that culture, and it would be possible for her to do so (live with her daughter). JM asked if the aspect of Ms. A's behavior that was making their living together difficult or untenable was known. The doctor said that she wanted her daughter to follow Ms. A's style of bringing up children. JM summarized then she was not respectful of her daughter's and her son‐in‐law's views on how they should bring up their children. She was critical of them. She would not accept the different way that they had decided to bring up their children.
JM responded that it is not only a matter of her beliefs about upbringing of children but it is also the matter of her actions. Ms. A insisted on criticizing and on influencing her daughter's family so that their family would be brought up in Ms. A's way. He then asked if she was aware that her intervention was going to influence the relationship with her daughter negatively. The doctor said that she knew of the effect that her behavior was having, but she insisted that hers was the right way. JM noted that although Ms. A's main need was one of being connected, her behavior was putting that connection in danger and asked if she was clear that her behavior was working against her own needs and that for the sake of doing things in the way that