In the introduction to the first patient story I commented that sometimes personal stories influence doctor’s opinions more profoundly than facts and science. This account is a poignant example of that observation because it concerns the psychotic depression suffered by an eminent former Dutch professor of psychiatry.
This is an account of the patient’s long illness (from the book he wrote, and a TV interview, and the doctor who treated him). I doubt English-speakers are aware of it; so, I have produced this account with the assistance of a Dutch translator.
It is the story of Piet Kuiper (1919-2002), a professor of psychiatry at the University of Amsterdam (1961-1984), who wrote a well-known Dutch textbook on psychiatry (‘Hoofdsom der Psychiatrie’) which was used by most Dutch universities. The book, like many others, relegated MAOIs into the ‘no good and too dangerous’ category: the kind of opinion that I have so long and so often railed against.
His psychotic depression was of great severity and failed to respond to the usual pharmacological treatments (TCAs, and antipsychotics). His illness began in 1982, and he was finally admitted to ‘Bloemendaal’ three years later, in Sept 1985. He was only in for a few weeks.
Here he was finally seen and treated by the well-known researcher Willem Nolen (Em. Prof. Psychiatry UMC Groningen, Groningen) in the Psychiatric Hospital ‘Bloemendaal’ in The Hague. I have corresponded with Willem Nolen about this case and he has checked this account for accuracy.
He recovered in a few weeks following professor Nolen’s treatment of him with tranylcypromine.
Professor Kuiper subsequently wrote the book ‘Ver Heen’ (‘Far Away’) about his awful experience (1).
The following account is summarised from the translations (book & video) provided to me by a well-informed Dutch patient, who contacted me via my website, (“Vince”) and Professor Nolen, to whom we owe our thanks.
Kuiper’s stance on MAOIs
He wrote, in the book ‘Ver heen’: ‘Professor of psychiatry writes textbook, vehemently opposes the use of a certain medication, then suffers from a depression and gets well again upon administration of the very same medication. Numbers are a deep mystery to me and can remain as such. I am however curious as to what the theory of probability would have to say regarding the odds of what had happened to me. Had this book been a novel, everyone would certainly remark as follows: ‘highly improbable, extraordinarily far-fetched’. But the reader knows: this is a report true to reality, not fiction’ (p 115).
It is no surprise to hear that Professor Kuiper later changed his stance on tranylcypromine, stating that although one needs to exhibit great care with regard to both the resulting hypotension and the dietary restrictions, ‘(tranylcypromine) is effectively a good medicine, of which I believe, hope, that it will be used more often (in clinical practice). It is very effective’. Van Dis in de IJsbreker (TV-interview) 1989.
The TV interview is on UTube
Kuiper’s depression before tranylcypromine
‘I hardly listened to music anymore. It made me fearful, how symphonies have an end. In the same way a piece of music follows, scurries its way to an end according to its own inner logic, irreversibly, so too had my life occurred; and all that had happened was in the past, unchangeable and irrevocable’ (p 85-86).
‘That which used to give rise to pleasant and uplifting daydreams, had become the starting point of gloomy considerations. Misery stood out to me; when I saw people laughing, I would think: how is such a thing possible in this horrible life?’ (p 59).
On the psychotic features of his depression: ‘Life is so incredibly horrible, I need to save my daughter from this. Well, I think you understand what I mean, I went on to think: I need to kill my daughter’. – Van Dis in de IJsbreker (TV-interview) 1989.
Professor Kuiper recalls having read the Greek tragedies in school, ‘of which many are inspired by the very themes that would come to dominate my illness: guilt, vengeance, aggression, and death’. Ver heen (p 32).
Professor Kuiper was initially convinced he was suffering from dementia [KG: Sadly, I must add here that I have seen several patients who have been relegated to care homes, or long-stay hospitals, with a diagnosis of dementia, when they actually had severe depression such as this. One of them, when we made his psychotic depression better (with TCP), described his improvement as “like being released from the grave”].
‘In Bloemendaal (the Psychiatric Hospital where Professor Nolen treated him) there was a horrible occurrence … I almost killed a nurse. I thank the heavens that I could only just barely (grabs and subsequently releases own throat in strangulation gesture) … I wanted to be transferred to a more heavily guarded unit before killing someone’. Van Dis in de IJsbreker (TV-interview) 1989.
This violent outburst, Kuiper states, was due to the brother in question playing chess on a chess machine. ‘This is hell. It can’t exist, such a machine. (…) This is someone from hell, I thought, and I grabbed his throat in the night. A tragedy was only just averted. Why I didn’t continue (the strangulation) but instead loosens my grip, I can’t tell you. But I am grateful for it’. – Van Dis in de IJsbreker (TV-interview) 1989.
Professor Kuiper later remarks: ‘It was a psychotic depression, a delusion: I have died, and this is a sort of hell. And the truly frightening part of it is that it so totally resembles normal life’. Van Dis in de IJsbreker (TV-interview) 1989.
On improvement with tranylcypromine
‘The inability to want, wish or desire anything is a symptom of depression. Because the fear and panic were so prevalent in the foreground of my disease, I hardly even experienced the listlessness, the having-no-interest-in-something as an additional source of misery. It was only when my interest and desires returned, that I noticed just how dreadful the previous lack thereof had been’. Ver heen (p 116).
Professor Kuiper states that (from the hospital grounds) ‘there was a beautiful view of the dunes. We [he and his wife, Noortje] were walking, then sat down on a small bench. The light sifted through the trees, and my wife said to me: “perhaps we still have some time left, together”. ‘Then I thought to myself: yes, that could well be true’. Van Dis in de IJsbreker (TV-interview) 1989.
During music therapy: ‘I felt it. That in me which had remained of ice, melted. I experienced the opposite of fear, an intense sense of security. A line of which I do not know the origin, suddenly came to me: “to make me breathe again”. The steel wires around my chest and soul uncoiled. My thoughts were in Amsterdam, with Noortje [his wife, who was due to arrive come visiting time]. Like a ship entering the dock at the harbour, the melody came to its evident end. It was a part from one of the Concerti Armonici from the Count of Wassenaar’.
[At this point the teacher, noticing Professor Kuiper’s difficulty communicating what he felt at present, prompted him] “Try”.
‘Tears rolled over my cheek, something I hadn’t felt in years’.
“How did you like it, can you say?”
‘I could hardly speak, but to remain silent would be in stark contradiction to my emotions. She [the teacher] smiled at me, like mother to infant.
Cold darkness had given way to light and warmth; the winds of spring roamed through, caressing the hilltops. I felt a boundless, limitless sense of happiness’.
‘What I think…’ Long pause, wiping tears with the back of my hand. ‘That life, regardless of all this bitter, horrible misery, is worth living’.
‘I heard her say: “You’ve recovered, I don’t think I’m wrong in saying this. You’ll be out of here in a couple of weeks”. – Ver heen (p 123-124).
Aside from the tranylcypromine, Professor Kuiper credits the music therapy at the hospital as having contributed greatly to his recovery [his training was psycho-analytic], his rekindled love for painting, as well the people in his life, above all his wife Noortje.
This case reminds me of a rather similar one I treated: a dear older lady who was intensely deluded about the evils she had committed, for which she entreated me send her to the police station, so they could lock her up. She improved so quickly on tranylcypromine that she returned home before the end of her second week in hospital (i.e. after 12 days on tranylcypromine).
I have written about the treatment of psychotic depression with tranylcypromine previously, see here
1. Kuiper, PC, Ver heen: Verslag van een depressie. Book, 1988: p. http://www.dbnl.org/tekst/kuip036verh01_01/downloads.php.
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