Thoughts About the Overdose Conundrum

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This article is in response to the article, “The Overdose Conundrum” by Benjamin Li, MD; Burhan Khan, MBBS; and Nidal Moukaddam, MD, PhD.

In the article “The Overdose Conundrum,” the words physician, psychiatrist, and less frequently doctor, are used interchangeably and I wonder what is behind Benjamin Li, MD; Burhan Khan, MBBS; and Nidal Moukaddam, MD, PhD’s need to switch among the three.

The article also states: “By definition, addiction is a relapsing and remitting illness. Similarly, depression is also a relapsing and remitting illness, but no one benefits from being kicked out of treatment for having a recurrent depressive episode.” That similarity must be contrasted with an obvious dissimilarity—namely that in addiction the relapse is initiated by the patient, whereas in depression the patient has not acted in any overt way to cause the relapse.

The more lenient the psychiatrist is when his patient is late, the later the patient comes, leading to an inevitable situation where the psychiatrist cannot see the patient that day which leads to both being angry. To rephrase, the psychiatrist’s leniency has inadvertently led to both he and the patient being disappointed, frustrated, and angry.

I learned this in a case where my patient committed suicide. “Ms Zee” was in my private care for 3 years. She complained of depression and was frequently very anxious. I acquiesced to her demands to be seen, often late at night, on weekends, and on holidays. She called one day to say she was feeling better. I told her I was happy to hear it, but that she must remember that her improved mood might not last. Thirty-six hours later, while her husband slept, she got up, pushed a chair over to the window and jumped from the sixth floor to her death.

Did my seeing her whenever she wanted contribute to her suicide? I think so. In my opinion, she was accustomed to my anticipation and response to her fluctuations in mood. I think she interpreted my lack of anticipation of her decision to commit suicide as an unexpected and disappointing flaw in my judgment and perhaps a rejection. To this, she reacted by committing suicide.

An interesting postscript: I tried to present her at a peer supervision group. The other members could not tolerate the beginning of my presentation of Ms Zee’s case. I was never able to do a peer psychological postmortem, to my great disappointment.

Dr Ronat is a psychiatrist and psychotherapist in private practice.