Adam Blatner, M.D.

August 12, 2010.   See also Art of Case Formulation for further practical applications;
  the "Real Diagnostic Variables,"   and review my papers by clicking above.

I’ve just been looking at Edward Shorter’s book, Before Prozac: The Troubled History of Mood Disorders in Psychiatry (2009, New York: Oxford University 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.)

I’ve also recently encountered a book by the surgeon, Dr. Atul Gawande, titled The Checklist Manifesto (2009, Metropolitan Books/Henry Holt & Co.), in 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.

There is 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 cross-section of 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.)

The term, “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 factors.

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!

Checklist on Depression

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.
    A. Are they living together, sleeping together, one or two beds? Do they cuddle anymore? Is there affection? If not, why not?
    B. What is the frequency of sexual relations? Degrees of satisfaction?
   C. Does the patient feel understood by his partner? Supported?
   D. 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 Close Others
    A. 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!
    B. How often are there visits? Are the others draining or nourishing, supportive or worrisome?
    C. Are relationships satisfying, do others enjoy them, are people proud or ashamed of each other?
    D. 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 about.

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?
     A. 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!)
     B. Is there a sense of being loved or protected by spiritual foroces greater than oneself, by Jesus, Allah, angels?
     C. 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.

7. Existential 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 investments?
    A. How much worry is given over to this?
    B. Is home secure or insecure, financially?
    C. 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.

13. General 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.

14. General 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.

16. Past 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 checked?

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 situations. You
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.

Thus, neither 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 positive factors.

I welcome your additions to the list above and comments. 

For responses, email me at adam@blatner.com

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