The office was smaller than he expected. Not in a way that mattered. Just enough that it felt contained. Nothing decorative, nothing staged. A desk, two chairs, books that looked like they had been opened more than once. There was a Bible on one of the shelves. James noticed it without meaning to. Then looked away.

The psychiatrist came in without any sense of hurry. Closed the door. Sat down. Looked at him first before reaching for the chart. “James,” he said.

James nodded.

“I read what your doctor sent,” he said. “But it’s usually better if you just tell me what’s been going on.”

James started with the tinnitus. “It’s not new,” he said. “I’ve had it for years. It just… stayed out of the way.”

“And now it doesn’t.”

“No.”

“How would you describe the change?”

James thought for a second. “It used to sit in the background,” he said. “Now it’s… in front of everything.”

The psychiatrist nodded. “And sleep?”

“Not good.”

“How bad?”

James let out a small breath. “I fall asleep. Then I wake up. And that’s it.”

“How long has that been happening?”

“A few weeks,” he said. Then added, “Feels longer.”

The psychiatrist made a note, but didn’t look down for long. “What about during the day?” he asked.

“I go to work.”

“I figured that,” he said, with a faint hint of a smile. “What I’m asking is—how does it feel when you’re not working?”

James leaned back slightly. “I don’t know,” he said at first. Then, after a pause: “I don’t feel much.”

The psychiatrist didn’t react to that immediately. “Give me an example,” he said.

James hesitated. “I play guitar,” he said. “Have for a long time.”

The psychiatrist nodded.

“I picked it up the other night,” James said. “Everything sounded right.”

“And?”

James looked down briefly. “Nothing happened.”

The psychiatrist waited.

“I kept playing,” James said. “Longer than I should have. Just… waiting for it to come back.”

He shook his head once. “It didn’t.”

A quiet pause settled in the room.

“Food?” the psychiatrist asked.

James gave a small, almost reflexive answer. “I eat.”

The psychiatrist tilted his head slightly. “That’s not really what I meant.”

James nodded. “I know. It’s the same,” he said. “I can tell what it is. I just don’t… care about it the same way.”

“And people?”

That one took longer. “I follow conversations,” James said. “I know what’s being said.”

He stopped there, then added: “I just don’t feel like I’m in it.”

The psychiatrist nodded once. Not surprised. “Let me ask you a few direct questions,” he said.

James nodded.

“Any thoughts about hurting yourself?”

“No.”

“Any thoughts that you’d rather not be here?”

“No.”

The psychiatrist held his gaze just long enough to be sure.

“Okay.”

“Alcohol?”

“Minimal.”

“Any change?”

“No.”

“Anything else? Medications, substances?”

“No.”

The psychiatrist leaned back slightly. “Have you had COVID?”

“Yes,” James said.

“When?”

“About a year and a half ago.”

“And how was it?”

James thought for a moment. “Not severe,” he said. “I didn’t need to be hospitalized. But I didn’t bounce back right away either.”

The psychiatrist nodded slightly. “In what way?”

“Fatigue,” James said. “Not extreme… but persistent.” He searched for the right word. “Flattened,” he added. “Like my baseline shifted a little.”

“Did it affect your concentration?”

“Some.”

“Sleep?”

James gave a short breath. “Looking back… probably.”

The psychiatrist made a brief note. “And work?”

That was where it changed. “My lab took a hit,” James said.

The psychiatrist looked up again. “How so?”

“Dermatology groups started selling,” James said. “Private equity. They didn’t want to deal with the administrative side anymore. Billing, compliance, all of it.”

“And that affected your volume.”

“Yes.”

James looked at the window. “2019 was the best year I ever had,” James said. The words came out cleanly. “After that… it never really came back.”

“Did you experience that as a loss?” the psychiatrist asked.

James didn’t answer right away. “It didn’t feel like a loss at the time,” he said. “It was gradual. One client. Then another. You adjust. You keep going.”

He looked up. “You don’t stop long enough to realize something changed.”

The psychiatrist nodded. “That’s often how it accumulates,” he said.

He took more notes then looked up. “And then the case,” the psychiatrist said.

James looked at him. “Yes.”

“Tell me about it.”

James didn’t go into detail. “It made sense at the time,” he said.

“And now?”

“It still makes sense,” James said. “But I keep going back to it anyway.”

The psychiatrist nodded. “What you’re describing,” he said after a moment, “fits with anxiety and depression.”

James sat with that.

“They overlap more than people think,” the psychiatrist continued. “We label them separately, but they usually come from the same place.”

“So this isn’t just… stress,” James said.

“It’s stress,” the psychiatrist said. “But it’s also what happens when it doesn’t let up.”

James nodded slowly.

“Most of the medications for this,” he said, “can make tinnitus worse. That’s the problem,” the psychiatrist said.

“I’ve had a few patients like you,” he said. “Still working. Still showing up. But something underneath isn’t lining up the way it used to.”

James didn’t respond.

“I’ve had decent success with a combination approach,” he said. “Clonazepam. Gabapentin.”

James recalled the drugs from medical school. 

“It’s not perfect,” the psychiatrist added. “But it can take the edge off without making the tinnitus worse.”

“And the goal?” James asked.

“Stability,” he said. “We don’t need to shut anything down. Just get you back to where your system can reset.”

They sat quietly for a moment. James glanced toward the shelf again. The Bible was still there. The psychiatrist followed his gaze briefly. Then said: “I’m a believer.”

He smiled.  “It doesn’t replace any of this,” he said. “But it does change how I think about what people go through.”

James nodded once. The visit ended simply. A plan. A follow-up. No pressure. In the car, James sat for a minute before starting the engine. The sound was still there. But it didn’t feel as undefined anymore.

When he got home, Deanna was in the kitchen. She didn’t ask right away. She turned, saw his face, and waited. “Well?” she said finally.

He set his keys down. He sat at the edge of the chair. “He thinks it’s anxiety–depression,” he said.

Deanna didn’t answer immediately. She took that in. “Okay,” she said quietly.

“He asked about everything,” James said. “Sleep. Work. Even COVID.”

“And?”

James rested his hands together. “I think it’s been building longer than I realized,” he said.

Deanna nodded slowly. “I’ve been wondering that,” she said.

He looked up. “Not just the last few weeks,” she added. “You’ve been carrying things… and not stopping.”

That landed. “He recommended treatment,” James said. “Medication.”

“What kind?”

“Clonazepam. Gabapentin.”

Deanna absorbed that. “Do you feel okay about that?” she asked.

James thought for a moment. “I don’t feel resistant to it,” he said. “I don’t feel… much about it.”

Deanna exhaled softly. “That might be part of it,” she said.

A small silence settled between them. “Do you trust him?” she asked.

“Yes.”

She nodded once. “Then we take the next step,” she said.

That night, James lay in bed. The sound was still there. But he wasn’t trying to push it away anymore. He was paying attention to it. And that, more than anything, told him this was real.

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