Autumn Woodbury had noticed the signs. As the mother of a 13-year-old daughter, she had been dreading the moment when they might appear; all the while hoping they would not. She herself had developed the symptoms at about age 9. She began to feel hopeless about nearly everything from friends to life in general. It had not passed, but it had been manageable. At least until now. Now seeing the slight changes in 13-year-old Ashley brought her a feeling of dread. How would Ashley cope with the depression and hopelessness? She had visited a counselor herself as a young adult and eventually, a psychiatrist. Medication had been prescribed and, while it did help with some of the symptoms, it did nothing for the dreary manila envelope that had been her life.
Autumn’s mother, Theresa, had told of her own depression, which began at age 15. She had always attributed it to the tediousness of life on a dairy farm, and had never sought any sort of medical treatment. People did not do that in the 1950s, and if you admitted to being depressed you were seen as week. Autumn considering her mother to be a strong person in both character and constitution. Weak was never a word she attributed to anyone in her mother’s family. Yet this personal weakness existed, for her mother, herself, and now, for Ashley. Autumn knew what was to follow: visits to psychologists and psychiatrists, meetings with teachers and counselors, and eventually, after nothing else worked, the medications. The medication that made her mouth dry and her head swim. Medications that took away her appetite and made her only want to sleep. She cringed. She had hoped Ashley would be spared this future, all the wild dreading the day when it would reveal itself.
She made an appointment for her daughter with the pediatrician Dr. Smith who, not surprising, found nothing out of the ordinary. Dr. Smith had seen all of the children in this small rural hamlet, and his career had spanned nearly four decades. He had delivered Ashley and her mother Autumn as well. He had known the family for many years. He was also aware of Autumn’s trouble with depression and even her mothers, and had assumed, not unrealistically, that there must be some genetic connection that would affect the women in the family. Dr. Smith shook his head after writing the referral for a psychological assessment. That family had bad luck. In addition, the only psychologist near by was a young woman who had moved to the area from Toronto. Apparently, she wanted to get away from it all. She chose the right place. Dr. Smith had met her once for lunch when she first opened her practice. She seemed nice enough. Yet if he were honest, he would admit it annoyed him when city folks moved north while the young people moved away to the city. Take that Jones boy for example. Hadn’t he gone to school in Toronto to be a psychologist or something? Why didn’t he come home to set up an office?
The psychologist was nice enough, and seemed to genuinely care about people. Dr. Elaina Zemrak had been a clinical psychologist in this small northern Ontario town for only three years, but she loved what she did. While the population would not support a clinician working only with children, children were nevertheless her passion. As she interviewed Ashley and her mother, she drew a picture of life on the Woodbury farm. Autumn’s husband Frank had been the supervisor for her father’s large dairy farm and when they married, Frank took over. Autumn’s father had passed several years ago, the result of a lifetime of hard work and often-inhospitable climate. Dr. Zemrak sat staring out the window after Ashley and her mother had left. She had scheduled Ashley for a follow-up appointment in a few days, but was not hopeful.
Her depression was mild, but it was real. According to Ashley, there was absolutely nothing for her to be depressed about. School was great, she loved living on the farm, and she loved nature. She was popular; a cheerleader, and had many friends. She volunteered at the local girls club and she tutored younger children in English and math. Yet, she exhibited symptoms of unipolar depression. Children can develop feelings of worthlessness or inadequacy over grades, social status, sexual orientation, or family life. However, this did not appear to be Ashley, who seemed perfectly normal in these domains. In fact, much better than normal Dr. Zemrak discovered. Depression may result from environmental stress, yet by all accounts, this too seemed remarkably upbeat. This was a mystery. One she was not certain she could solve, at least not with in the eight appointments authorized by the family’s HMO.
Dr. Zemrak feared that eventually, unless Ashley made progress on her very puzzling depression, she would end up where so many young patients did, on medication. She wondered why insurance companies would be so quick to stop talk therapy but so eager to support medication therapy. She had read the studies; the bulk of depression medication does little for the underlying cause, and often makes the patient feel worse. Then of course there is the suicide risk for teenagers using antidepressants. Yet, after their fifth appointment, she was no closer to understanding Ashley’s depression. He was thinking about this strange case when she ran into an old classmate at lunch. Peter Jones had been in many of Elaina Zemrak’s classes in graduate school, and they have become fast friends. Peter Jones was now Dr. Peter Jones, and after spending 5 years in child psychology had grown bored with treatment and became very interested in prevention. He left his practiced and pursued higher education in medicine and public health. He was only in town to visit family and did not know that Elaina still lived in the area. After sitting down in the booth and catching up, Peter told Elaina what he had been doing since the last time they spoke nearly 10 years ago. Always an insatiable learner, Peter had begun a graduate program in public health 8 years ago, and after earning a Masters in Public Health, he had gone on to a PhD program in epidemiology. Now working for a large hospital in Toronto, Dr. Jones had focused his dissertation where he had focused his psychological practice: on children. Of particular interest to Dr. Jones were parasitic infections.
Elaina seemed preoccupied, and Peter Jones, as an epidemiologist, was trained to notice the small things, and quickly commented on her distraction. She explained the puzzling case of a 15-year-old girl who had symptoms of depression, despite having no psychological background to explain it. She was outgoing, well liked, and kind, yet despite this, she was feeling depressed. Elaina explained that after several meetings, she was no closer to discovering the cause of her depression. Almost as a second thought, Elaina mentioned that it seemed to be a family trait, as both her patient’s mother and grandmother also suffered from depression. In no time, lunch was over and Elaina had to get back to her office, and Peter back to his parents, who were waiting at home. They exchanged phone numbers, addresses, and promise to keep better in touch. As Peter Jones’ hand touched the door handle of his rental car, he saw something out of the corner of his eye. It was with a sparrow. As Dr. Jones watched, he thought about the bird’s chances. Even if the poor bird escaped, cats have an enzyme in their saliva that acts as an anticoagulant. The poor bird would die faster if it just stopped fighting. But that was how nature worked, red in tooth and claw and all that. As he thought about the sparrow and the cat, he thought maybe the bird had some parasite or disease that would make the cat ill. Poetic revenge perhaps, and this made him smile. As he reached for the door again he stopped, saying aloud “Toxo,” quickly noticing the puzzled look on an elderly woman’s face standing nearby, also watching the events taking place on the sunny summer afternoon sidewalk. “Toxo” he repeated, and reached for his phone.
Quickly scanning the business card Elaina had given him, Peter Jones found the number and called her office. No answer, just a request to leave a message at the beep. Leaving his cell number and a brief message, he had nearly reached his parents home when his phone rang. It was Elaina. She asked why he had called and what was he saying about a bird and a cat? Dr. Jones asked if she had any upcoming meetings, and that he was on his way to her office.
When he arrived, Elaina met him at the door and, looking puzzled, she again asked about cats. Did her teenage patient have a cat? Elaina called Autumn’s cell phone and asked. The answer came back as a NO. Peter Jones leaned back in the chair, scratching his head. Elaina asked why he had asked such an odd question. Peter Jones, psychologist and epidemiologist, explained his thinking. Often parasitic infections in animals can accidentally infect humans. When they do, the symptoms can mirror a number of diseases, even psychological disorders. However, if her patient did not have a cat, then that was that. He apologized for the drama and was almost to the door, when he stopped, remembering what she had said during lunch: not only did her patient have depression, so did her mother and her grandmother. So, maybe it was more than a genetic component.
His next question struck her as very odd: “Did her mother have a cat when she was a child?” Again, Elaina reached for her phone. A moment later, she got the answer: YES. Not just a cat, many cats. According to Autumn, there were always a dozen or so barn cats around the farm to control rodents. Autumn’s grandfather had always kept several cats around and her grandmother used to housebreak a few favorites, trying to make them house-cats. Never actually worked too well. They were always wild.
The look on Peter Jones face went from puzzled to recognition. Seeing this, Elena thanked Autumn Woodbury for the answer and promised to call back when she understood more of what had just happened. Peter Jones explained that many cats, particularly cats that live outdoors and prey on mice could harbor a parasite called toxoplasma gondii. If a person is infected with this parasite, they can develop a reaction called toxoplasmosis. Elaina reminded him that her patient did not have a cat. He then explained that toxoplasmosis could also be congenital, passed down from an infected mother, or perhaps in this case, an infected grandmother through an infected mother, to a child. While many symptoms of toxoplasmosis are quite severe, other infections might be minor and not appear for years or even decades after initial infection. There was a simple test to find out if this was the case. Elena called the Woodbury Farm and explained what she had discovered. Then she called Dr. Smith’s office and arranged a blood collection for Autumn and Ashley Woodbury.
While collecting samples is quick and relatively easy, obtaining the lab results would take some time. Two weeks later, the phone in Dr. Peter Jones’s office rang. It was late on a Friday afternoon, and Dr. Jones considered letting the answering service pick up. It has been a long day, and he decided whatever it was good be dealt with on Monday. As he closed his office door, his cell phone began to rain. Aside from his secretary, his supervisor, and his family, few people had this number. Answering, he recognized Elaina’s voice. “You were right,” she said, sounding out of breath. She had just heard from Autumn Woodberry and both she and Ashley tested positive for toxoplasmosis antibodies. Dr. Smith had started them on pyrimethamine and sulfadiazine, and added a daily dose of folinic acid for good measure. The two planned to get together again, when Peter was next in town.
The following November, Peter Jones and Elaina Zemrak sat down at his parent’s home for thanksgiving dinner. After, they drove to the Woodbury Farm so he could meet the family he had helped. He was glad he could help and had often wondered what the outcome had been. Drinking coffee at the table and watching to snow drift outside, Autumn spoke of the changes she had seen in Ashley. Although Autumn had some benefit from being free of the infection, Ashley had responded amazingly. The happy child she had known for the fist 13 years had returned. On the drive back to the Jones, Elaina asked if Peter had ever considered moving back home? “It’s too quiet here” was his reply.