Welcome back to Case Conference, and greetings to first timers. Here’s where we left off last time.

A depressed businessman is separated from his wife; he’s taken several antidepressants which he claims only help for a short time. He has two children, including a boy with Down Syndrome and the thought of breaking up the family is heart-breaking. He and his wife are trying to make a go of it, but he got it in his head that she’s interested in another man; now he wants a different antidepressant. What next?

Not much question about this one, readers and colleagues agreed to a person. “This man doesn’t need more medication,” they say. “He and his wife need therapy!”

Chronic depression and relationship discord compromises the workplace via sick days and under-productivity, and is associated with costly medical workups to rule out medical disorders (cardiac and GI evaluations alone can run into the thousands of dollars), so let’s not kid ourselves into believing that just because people can survive dysfunctional relationships, the “worried well,” as they’re often denigrated, are far from healthy.

There’s a saying I share with people in situations like today’s patient: “The only thing worse than being unhappily married is being unhappily divorced!” True, we have antidepressant and mood stabilizing medication to ameliorate symptoms, but when it comes to relationship issues, individual and conjoint psychotherapy is essential. Too many couples muddle through discordant relationships and, no matter whether they divorce or stay married, wind up in unresolved, unhealthy relationships. Although chronic relationship stress may be hard to quantify scientifically, just ask the family and friends of an unhappy, disgruntled couple, and to a person they’ll confirm what a waste it is; not to mention how important it is that parents set good role models concerning compromise and conflict resolution for their children.

The major issue facing the man in today’s case was the seething but unstated resentment between him and his wife over coping with their special needs child, who was now eight years old. Katharine, the wife, felt that her husband James pressured her into having a late-life child. Katharine was well into her forties—later life pregnancy carries a higher risk of Down Syndrome—by the time the child was conceived; she was happy with two children, but agreed to try for a third child because James wanted a boy to name after his father, who died suddenly of a heart attack in his mid-sixties. The couple went through an elaborate fetal-maternal medicine procedure to predetermine that the child would be male.

What depressed James and got him wanting another child was his sense of fragility upon entering the second half of his life. It was more than mid-life crisis that James felt. He had modeled his career after his father, a man who toiled faithfully for a large corporation before retiring at age 65, only to die suddenly soon thereafter before realizing his dreams of joining several recently retired colleagues in activities and pursuits he had long deferred, claiming, “Once I retire, I’ll have all the time in the world to do what I like.”

“How could this happen?,” James reflected about his father, a man who sacrificed so much, including time with James and his siblings, to achieve financial success. The death shocked James into realizing there was no guarantee about a golden future. For James it was much more than the death of his father. It was the death of a dream.

In his depression, James envisioned life with his special needs child as joyless and frustrating, depriving him of the chance to be the father to his son that he wished his father would have been with him. He defended himself from this feeling by distancing himself from Katharine who, as their son required more and more social service and school interventions, came to feel emotionally abandoned. Meanwhile James buried himself in his work where he began receiving poor reviews from his clients because his acuity was compromised by the vicious cycle of relationship stress and depression. Medicine alone couldn’t address James’s pathological mourning over the death of his cherished dream.

The good news was that James’s psychiatrist insisted on individual and conjoint psychotherapy as a condition of continuing medication therapy and referred him to an astute therapist who zeroed in on James’s grief issues quickly. Therapy helped him see that there was joy to be found in recognizing his son’s everyday achievements, as opposed to dreaming of an idealized future. The therapist also got James and his wife involved with a local support group for families with special needs children. His son’s outpouring of love and joy in seeing his father more engaged proved inspirational. And, once James became more emotionally involved in family life, Katharine felt less estranged and neglected. Life turned out much differently than James expected, but to his credit he found the courage and flexibility to build new dreams.


Jeffrey Deitz, M.D., is a psychiatrist and psychoanalyst in Connecticut and New York City.  He supervises psychiatrists-in-training in New York and teaches at Quinnipiac University School of Medicine in Connecticut. His articles about sports psychology, psychotherapy, and sleep deprivation have been published in the New York Times and Huffington Post. In 2016 Dr. Deitz published his first novel, Intensive Therapy: A Novel, a fiction work about the life-saving relationship between a psychiatrist and patient.