A "CHECKLIST" FOR DIAGNOSING
I’ve just been
looking at Edward Shorter’s book, Before
Prozac: The Troubled History
of Mood Disorders in Psychiatry (2009, New York: Oxford
Press). (He’s written a number of other books on the history of
psychiatry, too.) Dr. Shorter notes that the evidence for
the use of common antidepressants is ambiguous. I’m not surprised,
given that most of the medicine prescribed for this purpose is
prescribed by non-psychiatrists---mainly family physicians, internists,
and other primary care providers. Depression may be a particularly
broadly inclusive diagnosis, equivalent to “tummy-ache.” (One might
plausibly argue also that although anti-depressants are probably
over-prescribed for many people, there is also a large number of people
who might benefit yet who are receiving neither trials of these kinds
of medicines nor even an evaluation for consideration of such a trial.)
recently encountered a book by the surgeon, Dr. Atul Gawande, titled The
Checklist Manifesto (2009, Metropolitan Books/Henry Holt &
which he notes the use of checklists as a tool for coping with
extremely complex systems—not just surgery or complex medical
interventions, but also for pilots, at construction sites, in
restaurants, and elsewhere. This essay’s point is that I think we
should use a checklist approach to psychiatric or psychotherapeutic
interventions, and that this might help clarify the issues noted by Dr.
Shorter regarding depression.
increasing evidence that medicines don’t work all the time for
“depression,” though the term itself may be vulnerable to a significant
generality. I subject anyone with that possible diagnosis to an
interesting test that I made up---the test operating in my own
imagination as I take the history. I call this diagnostic technique
"the daytime talk-show-audience test." It
works like this: What if this patient’s life could be made into a
well-edited documentary that captured all salient elements (to be noted
below)—all factors that added stress or in other ways contributed to
the depression. As I'm taking the history, I consider categories such
as the state of the patient's marriage, family, work, social
integration, faith, etc. Then I imagine this "documentary" (i.e., the
story that I'm eliciting from the patient) were to be shown to
an imagined daytime television show audience—i.e., a
ordinary folks. Following this line of thought, I imagine the audience
having two types of reactions: (1) Wow!
If half that stuff were happening to me, I’d be twice as depressed if
not rather crazy! Or, (2) Gee, there are some stresses, but no more
than a lot of people I know. His (or her) depression seems out of
proportion to these stresses. If it’s (1), I look more intensively for
the various stresses and realize that even if we used medication, it
might not work that well unless some of the stresses or the overall
load of many factors were ameliorated. If it’s scenario (2) I think
there’s a greater likelihood that some medication may make a greater
difference. (Sometimes it's both.)
“psychotherapy,” is often imagined as being more relevant for patients
in the first category, though it applies also for the second. Yet I
fear that most forms of psychotherapy fail adequately to ameliorate the
most common stresses—or even clearly elucidate their existence. Most
psychotherapies are overly aimed at the psychology of the client, and
I’ve been disillusioned too many times as a supervisor in discovering
that the therapist has hardly opened the pandora’s boxes of low or
higher-grade addiction, family dysfunction, and other perpetuating
It occurred to
me that most treatment and most research about depression, anxiety, or
other general diagnoses—and these are by far the most commonly made
diagnoses—tend to ignore at least several of the types of factors to be
mentioned below, and hinted at in option (1)
above—i.e., the most common stressors that tend to make people unhappy.
So let’s create a preliminary checklist. My hunch is that unless
therapist or diagnostician and patient or client have reviewed and
explored this checklist in dialogue, it’s entirely possible that the
most relevant factors in the disease continue to be overlooked—in which
case, medication is not likely to suffice as a treatment!
1. Marriage: Is
there a marriage, companion, partner? Basic degrees of closeness?
Likelihood of breaking up? Verbal statements of support (at least)? If
not, this is a biggie.
Are they living together, sleeping together, one or two beds? Do
they cuddle anymore? Is there affection? If not, why not?
What is the frequency of sexual relations? Degrees of satisfaction?
Does the patient feel understood by his partner? Supported?
What is the degree of contentment, dissatisfaction, guilt, burden, etc.?
There are other questions that might open up depending on the
answers. But they need to be asked about—the old technique of letting
the patient just talk is most susceptible to the tendency of patients
to withhold crucial details, both not wanting to admit certain
vulnerabilities or worries to the interviewer, or from denial—not
wanting to admit stuff even to oneself!
2. Concern About
Often people with depression are burdened by worries about kids or
parents, seriously ill or disturbed siblings or friends—and these
worries may not be brought up as relevant to the depression!
How often are there visits? Are the others draining or nourishing,
supportive or worrisome?
Are relationships satisfying, do others enjoy them, are people proud
or ashamed of each other?
Have there been some break-ups, loss of closeness? Do some of these
losses evoke a sense of guilt—often partially or considerably valid—due
to pride, hasty retaliation, and so forth. Have any efforts at
reconciliation been made?
3. Are there
continuing addictions of any kinds? This is a very common type of
co-morbidity. It may not be mentioned, and may not be considered to be
thus, but the key is whether any behavior patterns result in
significant loss of meaningful time, drain from meaningful
relationships, leave residues of feelings of shame and vulnerability,
etc. Included are subtle shopping addictions, spending or going
into debt, food addictions, sexual addictions, television or internet
addictions, draining primary relationships of their time together, etc.
A subtle distraction from engagement from life can feed shame and
depression. A wide variety of other patterns need to be asked
4. Is there
residual shame or guilt for behaviors in past wars (for veterans), for
the consequences of alcoholism or other lapses in social behavior,
petty crime, and so forth. Often patients will not volunteer such
dynamics but they operate as seeds of demoralization as much as a
pocket of undiagnosed infection may resist treatment by an antibiotic.
5. What is the
job situation: Is it satisfying? Is it secure or is the patient
vulnerable to being fired? Does the patient even have a job? Has she
been looking or has she given up or something in-between? Does the
patient know he has employable skills? What have recent changes in
technology done to those skills?—some have become somewhat obsolete.
What is the situation with job politics, supervisors, subordinates,
colleagues? Are there petty politics that drain morale? Patients may
not feel they can bring this up with their therapists, but for some
this stress is significant!
6. Is there an
operant faith or meaning system, a religion, certain symbols of
meaning. Has the individual fallen away from what was at one time more
supportive, either actively or passively? Why? Are there feelings of
betrayal by God, the minister, or one’s congregation?
Does the person have a sense of personal purpose, some gift or
calling, and is it still perceived as being needed in the world? (Many
people lack this!)
Is there a sense of being loved or protected by spiritual foroces
greater than oneself, by Jesus, Allah, angels?
Patients will often avoid talking about such things unless the
therapist or social worker or case worker explicitly asks about it!
Indeed, this is true for most of these categories—sex, close others,
lost relationships, etc.
morale: Is one’s world going anywhere positive or heading “down the
tubes.” Is there an overall or even partial sense of optimism? Some
people’s depression is due in no small part to their becoming caught up
in a fair number of negative attitudes that are fairly realistic!
8. What about
money, savings, debt, prospects for further income, security of
How much worry is given over to this?
Is home secure or insecure, financially?
Are there major anticipated expenses?
9. What are the
patient’s sources of recreation, pleasure, play, escape? Therapists
often fail to systematically investigate what patients might do if they
weren’t depresssed. Answer for many: nothing much. How much energy is
absorbed in pseudo-play, such as television and other vicarious
spectator sports. I suspect that 20% is okay, but when it hits 50%,
there mounts a sense of self-indulgent escape from the inner
injunction, leading to a lowering of self-esteem.
10. What other
achievements have been made in the past year? These need not be
official. Learning a skill, helping another, reaching out, making a
breakthrough in habit breaking, reconciling with a friend—these are
often the kinds of experiences that reinforce reslience, like vitamins
for the soul.
11. What is the
level of social integration, the number of clubs, attendance, the
number of friends who are known by name, more than face recognition?
Draw a little map, a circle of these folks: How many are they, and what
is the state of the relationship? Has there been reciprocity, or
face-to-face or even phone or email contact.
12. Any other
losses not mentioned: Loss of any abilities, even minor, due to health
or other reasons? Deaths or worry over dying? Sicknesses and falling
behind, growing old enough to feel “out of it” without developing
compensatory enjoyments. A sense of life wasted, being a failure? Some
of these may be exacerbated by the biological elements of depression,
but sometimes they sustain a depression.
psychological mindedness or sense that one can learn to manage one’s
own mind, habits of thinking, directing positive thoughts, working out
negative thoughts. For many people this is almost a non-category.
levels of overall weaknesses or strengths. Many people suffering from
drug-resistant depression are also afflicted with a goodly number of
other forms of emotional fragility, chronic feelings of victimization
or helplessness, a lack of real achievements, and so forth.
15. Realities of
socio-economic support, in terms of being able to afford vacations,
travel to see the therapist, the cost of even co-payments for
hospitalization or medications, people to help in any way, hostility
from the family, and so forth.
experiences with therapy or other kinds of helping. Often there are
residues of suspicion, fear, and hopelessness based on previous
experiences. Some of these may have been due in large part to the
patient’s unrealistic expectations or distortions, but some reflect the
realities of the broad range of types of “care” in our current
system—the quotation marks because many people feel previous
psychiatrists or therapist have been less than caring. Some also feel
(with fair validity) that their previous helpers have been foolish or
flawed in fairly obvious ways. While we should not be too quick to
assume that previous therapists were flawed—some patients play to this
to set up the next therapist in line—neither should therapists or
social workers be closed to the idea that past efforts at helping were
indeed inadequate, if not actually toxic. There are many horror stories
about experiences with hospitalization, especially. Also, if the
patient hasn’t had a negative experience, she may have a close friend
or relative who has.
Jenny Wilson in New Zealand suggested the following additions, and I agree:
17. Physical health (which the client may not be aware of and therefore
does not report). Especially have iron levels and thyroid hormones been
18. Rumination and thinking style. Some people just can't help
ruminating! They have a habitual tendency to slip into extensive and
largely unnecessary and unhelpful thinking for hours and hours. Some
types of therapy make this problem much worse! with the client
developing the unhelpful belief that, "If I just think about my
problems long enough I will find an answer." Some people don't realize
the effect of unproductive rumination on mood and for them it may be a
new idea to try and manage this. (I have found the occasional long term
depressed client who has experienced huge improvement in mood just by
finding ways to manage rumination).
19. Anxiety and avoidance. Some of the most difficult to treat
depressed clients I have met have had an interesting combination of
anxiety and depression. However they do not report any anxiety symptoms
because they are managing anxiety by avoiding any anxiety provoking
will not see the anxiety until you put some pressure on for them to try
something new. Typical picture here is the youngish male client who
reports that he is unconcerned about lack of friends and social life,
says is really not interested in meeting people and spends more time on
his computer than with live people. Interestingly many of these clients
also have unusual sleep/wake patterns: They’re up all night on computer
and sleep during the daytime.
These may overlap with some of the other items but are important enough to consider separately).
These are some
of the kinds of things that can keep a depression going. The person has
every reason to remain unhappy. Sometimes ordinary psychotherapy alone
can’t remedy this, either. What’s needed is a thorough evaluation,
almost with a checklist, looking at all of the aforementioned elements.
The ideal therapist in my thinking would be partly a social worker and
partly a community worker—and maybe partly a pastoral counselor,
occupational therapist, vocational counselor, career coach, conjoint
family and social network therapist, etc.—at least in terms of the
inter-disciplinary perspectives included.
medication management nor ordinary one-to-one therapy may suffice:
Ordinary therapists with less than a checklist and comprehensive view
may miss some of the aspects of life mentioned above. These can be real
stresses, and some may be far greater in inner impact than the topic
may suggest. Karl Menninger talked about “the vital balance,” and for
some, there are too many draining factors and not enough compensating
I welcome your
additions to the list above and comments.