More Studies Reveal Widely Known Facts to be Actually True

As I did on my posts of November 30, 2011,  October 2, 2012,September 17, 2013, June 3, 2014, February 24, 2015, and December 15, 2015, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of the latter. My comments are in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

This last few months has been such a treasure trove of studies of the obvious, my descriptions of the individual studies listed will be a little briefer than usual.

At the end of today's issue of No Sh*t Sherlock is a special section on some new shocking and counterintuitive findings about things we used to think were good for your mental health and well-being - but turned out not to be.

12/15/15. Adolescents Who Abuse Prescription Pain Medicines May Be More Likely To Have Sex, Participate In Risky Sexual Behaviors

HealthDay (12/15, Haelle) reports that adolescents who abuse prescription pain medications may be “more likely to have sex or to participate in risky sexual behaviors,” a study published online Dec. 14 in Pediatrics suggests. 
Impulsive, self destructive people were, I guess, previously thought to be highly selective in which impulses to indulge.

12/15/15. Study Shows Reduced Patient Satisfaction When Computers Are Used Excessively In Exam Rooms

On the front of its Personal Journal section, the Wall Street Journal (12/15, D1, Reddy, Subscription Publication) reports on a study published the previous month in JAMA Internal Medicine, which found that patients whose doctors spent a lot of time looking at a computer screen during examinations rated their care lower. 
And here we thought that patients just hate doctors who pay close attention and listen to them carefully.

12/23/15. College Students Who Smoke Marijuana Appear More Likely Than Their Peers To Skip Classes

HealthDay (12/23, Norton) reports, “College students who smoke marijuana appear more likely than their peers to skip classes – which eventually leads to poorer grades and later graduation,” a study published in the September issue of the journal Psychology of Addictive Behaviors suggests. 
This finding is just so difficult to explain.

1/6/16. Many Single Mothers with Minor Children are Sleep-deprived, CDC finds

The Los Angeles Times (1/6, Kaplan) reports in Science Now that a data brief from the Centers for Disease Control and Prevention’s National Center for Health Statistics reveals that “44% of single moms living with children under the age of 18 fall short of recommendations to get at least seven hours of shut-eye each night.” Thirty-eight percent of single fathers who live with their children “sleep less than seven hours per night,” the report found. 
I just don't understand why these parents can't make their days last more than the usual 24 hours.

1/22/16. Prevention Programs for Youth Most Effective When At-Risk Families Are Clinically Stable

Programs that teach stress management and cognitive-restructuring skills may help to prevent the onset of depression in teens at high risk for depression, but how effective they are appears to depend largely on the mental health of youth and their parents when the intervention begins, according to a study published online this week in the Journal of the American Academy of Child and Adolescent Psychiatry. 
At last the long-sought proof that the more severe a disorder, the worse the prognosis tends to be.

3/2/16. Study Suggests Factors Predictive of Violent Behavior in People With Mental Illness

Results from a meta-analysis in Psychiatric Services in Advance shows that three factors may be associated with an increased risk for adults with mental illnesses to commit community violence in the near future. They are alcohol use, exhibiting violent behaviors, and being a victim of violence within the past six months. 
Booze fuels violence? Past behavior a predictor of future behavior? Who'd'a thunk??

3/16/16. Disruptive Patients may Get Worse Care from Physicians

HealthDay (3/15, Dotinga) reports, “‘Disruptive’ patients may get worse care from physicians,” studies suggest. 
Can't be. Doctors have been trained to be completely unaffected by annoying people. (Well, psychoanalysts anyway).

4/21/16. Eating Disorders May Be More Prevalent At Schools With A Greater Proportion Of Female Students

HealthDay (4/20, Preidt) reports, “Eating disorders may be more prevalent at schools where a greater portion of the student body is female,” research suggests. 
I just never noticed the higher prevalence of women among patients with anorexia and bulemia.

5/25/16. Severely Obese Children Picked On, Bullied More Than Normal-Weight Kids

HealthDay (5/25, Reinberg) reports, “As early as first grade, severely obese children are getting teased, picked on and bullied more than normal-weight kids,” research published online May 25 in Child Development indicates. Researchers arrived at this conclusion after gathering “data on nearly 1,200 first graders from 29 rural schools in Oklahoma.”  
Did these researchers ever go to grade school?

5/27/16. Depressed Patients Who Attempt Suicide Four Or More Times May Have Higher Risk Of Eventually Dying By Suicide, Research Suggests

Medscape (5/26, Brooks) reports, “Depressed patients who attempt suicide four or more times have a higher risk of eventually dying by suicide compared with their depressed peers who have never attempted suicide or who have done so fewer times,” research suggests. 
The fifth time is the charm.

6/2/16. Higher Out-of-pocket Costs Lead to Reduced Adherence

A literature review of 160 articles and abstracts identified a clear relationship between cost sharing, adherence, and outcomes. Of the articles that evaluated the relationship between changes in out-of-pocket costs and adherence, 85% showed that increasing patient out-of-pocket medication costs leads to reduced adherence. 
Did these researcher ever hear of the law of supply and demand? Guess not.

6/16/16. Hospital Deaths more Costly and Involve More Tests and Procedures than Deaths at Home

On its website, NPR (6/15, Kodjak) reports people who die in hospitals “undergo more intense tests and procedures than those who die anywhere else” and that more is spent on people dying in hospitals compared to people who die at home, according to an analysis by Arcadia Healthcare Solutions. 
I was wondering about that (not!)

7/1/16. Problem Of Missed Medication May Increase With Age, Failing Memory

HealthDay (6/30, Preidt) reports that a study published in the Journal of the American Geriatrics Society “suggests that the problem of missed” medication “rises with age and failing memory, especially for men.” The investigators found that other factors linked to “medication lapses” were “memory deficits” and having “trouble with the tasks of everyday living.” 
Gee, people with memory problems forget things.

And now for the special section that details how we have recently discovered that many things in the environment that were once thought to be sources of tremendous joy and uplift turn out to actually be downers that create various negative feeling states and are risk factors for depression and anxiety.

These include childhood abuse and neglect, poverty, post-partum depression, traumatic experiences, cancer, kids having parents with chronic severe migraine headaches, having your livelihood threatened by a disciplinary action from a licensing board, diabetic retinopathy, having a premature infant, and combat experiences.

I bet you think I'm making this up. Sorry, but you just can't make this stuff up.

3/1/16. Study finds children who face adversity before age 5 struggle in school

Kaiser Health News (2/29, Gillespie) reports a study published in the journal Pediatrics found that “adverse childhood experiences [ACEs] before age 5,” including “neglect, abuse and dysfunctional home lives,” were associated “with poor academic and behavioral performance in kindergarten.” 
These researchers just don't understand that these kids just have ADHD.

3/17/16.  Low-Income People Exposed To Rats In Urban Environment May Be More Likely To Have Depressive Symptoms

According to the NBC News (3/16, Fox) website, a study conducted by the Johns Hopkins Bloomberg School of Public Health and published online Feb. 10 in the Journal of Community Psychology reveals that “people living in Baltimore’s low-income neighborhoods who see rats as a big problem are significantly more likely to have depressive symptoms such as sadness and anxiety.” 

3/21/16. Women Who Have Had Postpartum Depression May Not Have More than Two Children, Study Indicates

HealthDay (3/18, Preidt) reported, “Women who’ve had postpartum depression may not have more than two children,” the findings of a study published in the January issue of Evolution, Medicine and Public Health suggest. 
Depression was previously thought to be so much fun that everyone wanted to go through it as many times as possible.

4/25/16.  Exposure To Traumatic Events May Be Associated With A Host Of Potential Negative Behavioral And Physical Effects

Medscape (4/25, Melville) reports, “Exposure to one or more potentially traumatic events in a lifetime is associated with a host of potential negative behavioral and physical effects, ranging from mental illness and depression to substance abuse, asthma, and” hypertension, the findings of a new report from the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality indicate. 

4/28/16. Cancer Diagnosis may be Associated with Increased Risk for Anxiety, depression

HealthDay (4/28, Preidt) reports that research published in JAMA Oncology “details the psychological damage” a cancer diagnosis “often leaves in its wake for patients.” Investigators “found much higher rates of anxiety, depression and even drug and alcohol abuse for those who’ve been told ‘you have cancer,’ compared to healthier people.”  Healio (4/28) reports that the study indicated “the risk for mental disorders appeared stronger among patients whose cancers had poorer prognoses.” 

       

5/31/15. Childhood Trauma May Increase Risk of Adolescent Drug Use, Study Shows

Children who experience traumatic events prior to the age of 11 may be more likely to use marijuana, cocaine, nonmedical prescription drugs, or other drugs as teens, according to a report online in the Journal of the American Academy of Child and Adolescent Psychiatry. 

6/27/16. For Teens, Living With Parents Who Have Chronic Migraine May Negatively Affect Activities Of Daily Life, School Performance.

Medscape (6/24, Davenport) reported, “For adolescents, living with parents who have chronic migraine has a negative effect on activities of daily life and on school performance and is associated with increased rates of anxiety,” research suggests. 
Parental misery and pain were previously thought to have no effect on their children whatsoever.

7/15/16. Patient Complaints Against Physicians and the Ensuing Complaint Review Process Seriously Affect Physicians' Long-term Psychological Well-being 

and can lead to their practicing defensive medicine, results of a large qualitative survey show. Led by Tom Bourne, MD, PhD, from the Department of Surgery and Cancer, Imperial College London, United Kingdom, the study is an analysis of responses to qualitative questions as part of a larger anonymous survey completed by almost 8000 physicians. 

7/8/16.  Severe Diabetic Retinopathy May Be Associated With Depression, Study Suggests

MedPage Today (7/7, Minerd) reports, “Severe diabetic retinopathy...was linked to depression, and its presence should prompt clinicians to inquire about a patient’s mental health,” research suggested. The findings of the 519-patient study were published online July 7 in JAMA Ophthalmology.  

7/21/16. Parents Of Extremely Premature Infants May Be More Likely To Become Depressed Than Parents Of Full-Term, Healthy Infants

Reuters (7/20, Rapaport) reports, “When babies are extremely premature, parents are about 10 times more likely to become depressed than mothers and fathers of full-term, healthy infants,” research suggests. Included in the study were “113 mothers and 101 fathers of preemies, as well as 117 mothers and 151 fathers of healthy, full-term infants.” The findings were published online July 18 in JAMA Pediatrics.

8/12/16. Female Service Members who Experience Combat may have Much Higher Risk of PTSD than Those Who do Not

Reuters (8/10, Rapaport) reports, “Women in the military who experience combat have a much greater risk than those who don’t of developing post-traumatic stress disorder (PTSD) and other mental health issues,” researchers found after examining “data from post-deployment mental health screenings for more than 42,000 women enlisted in the US Army and deployed in Iraq and Afghanistan from 2008 to 2011.” The findings were published online Aug. 1 in the Journal of Traumatic Stress. 

I wonder how many other things that were once thought to joyful actually are not.

Book Review: Prescriptions Without Pills by Susan Heitler

When I first started to develop my integrative psychotherapy paradigm, unified therapy, a central problem I focused on was how patients could fruitfully discuss sensitive family dynamics with their parents without the conversation turning into just another variation on the same exact dysfunctional theme. How could someone confront highly invalidating and/or abusive parents about their interactions, with a goal to stopping them, without the conversation devolving into mutual rage, defensiveness, attacks, and/or emotional cutoffs?

I was amazed at how family members could be such experts at re-framing something meant to be constructive back into something highly destructive. Readers of the comments to my blog posts on Psychology Today know that even today many people think I am the insane one for even thinking it is possible to interrupt this admittedly highly malignant process.

After I first developed and wrote about some good strategies for keeping things constructive, I came across a helpful book by Susan Heitler, Ph.D., called From Conflict to Resolution (W.W. Norton, 1990), which described several strategies for detoxifying toxic interchanges between intimates as well as between patients and therapists. The book helped me to refine and expand upon my repertoire of strategies. Since every family and family member responds differently, the more strategies I have in my bag of tricks, the more different patients I can help.

I later briefly met Dr. Heitler at a meeting of the Society for the Exploration of Psychotherapy Integration, an organization to which we both belong. Its purpose is to look into ways to integrate various ideas from the different "schools" in psychotherapy— primarily the psychoanalytic/psychodynamic therapies and cognitive behavior schools.

(As an aside, I have since become less involved with the organization for two reasons. First, the leaders of the group were afraid that if they succeeded in devising an overarching theory, then they would just become yet another therapy school. I, on the other hand, was tired of exploring and was interested in actually doing. Second, family systems and social psychology were woefully underrepresented in the group. Since humans are among the most social of organisms, that just seemed crazy).

Dr. Heitler has now written a self-help book for lay readers which goes over a lot of the same territory as the Conflict book, Prescriptions Without Pills: For Relief of depression, anger, anxiety and more. The title stems from an opinion we both share: today there has been an explosion of excessive prescribing of anti-depressant and anti-anxiety medication to clients who just have problems in living. While she is not against the use of medication, it is often just plain ineffective for many problems with which people come to mental health professionals. Antidepressants for example, as I have written about many times, are completely useless for chronic unhappiness as opposed to Major Depressive Disorder.

The book is chock filled with very useful suggestions for people who are locked into what were once termed neurotic styles. (See the book of the same title by David Shapiro from way back in 1965). The term neurosis has unfortunately now been practically banned from psychological discourse and psychiatric diagnosis because its role as a "cause" for any psychological problem has not been "proven." 

It refers to problems created for people because of internal conflicts between what they would like to do based on their own preferences and what they think they are supposed to do based on the "rules" they have learned from their ethnic group, religion, and most importantly their families of origin. "Style" refers to such things as ways of thinking and perceiving, modes of subjectively experiencing other people, and repetitive, unthinking types of stereotypical behavioral transactions in various circumstances within one's interpersonal relationships.

People who will benefit most from this book are those who learned these styles growing up and who have gotten into some bad habits which create sadness (the author uses the word depression but seems, at least in this book, to have conflated major depression and dysthymia, the differences between which are elucidated in this post), anxiety, anger, and/or addictive behavior—but who are generally functioning fairly well in some areas of their lives, have minimally cordial relationships with their parents and siblings, and are highly motivated to change. They will find the suggestions in the book quite helpful in getting problematic behaviors and feelings under control. This in turn will help them with their love life and their work life as they interact with others.

I do not believe that people with more severe personality pathology and highly dysfunctional families will be able to successfully avail themselves of these strategies for reasons I will also mention in a bit. So this book will not be as helpful for folks like that.

Dr. Heitler describes the typical habitual ways neurotic people respond to problems, particularly interpersonal ones. The one healthy one is to define and boldly face the problems and to work on solutions to them. The unhealthy ones include folding (leading to discouragement and low moods; fighting (leading to anger and aggression); freezing (leading to chronic anxiety); and fleeing (obsessively burying oneself in a substance or behavior and becoming addicted to it).

A big part of the techniques for changing the bad behavior when it starts to occur is stopping and thinking about what the real nature of the problem is, as well as the reasons behind one's own seemingly overly-strong, over-the-top emotional reactions. The reasons for those are often past experiences with important attachment figures (emphasis on the word past. If those experiences are ongoing, that's a 'hole 'nother level) which bring up strong feelings.

For instance, if when you were growing up your divorced father frequently did not show up for his visitation days when he was supposed to, and in response you started to think that you are basically unlovable, then any time another person disappoints you, you might over-react even if the other person had a very valid reason for not doing what you had expected. 

This is actually a way of conceptualizing what the psychoanalysts call transference. Many cognitive behaviorists claim they don't believe in it, even though they actually do but just call it by another name: mental schemas.

Dr. Heitler recommends visualization techniques one can use to let one's mind recall the important precipitating events from one's past. The techniques can be thought of as another way of employing what the analysts call free association.

She also suggests many useful questions to ask oneself and ways of thinking that one can use to explore one's own psyche, to change perceptions about what other people might really be doing and thinking, and clarifying dilemmas in life. She describes how one can use their own strong feelings as a vehicle for constructive engagement with other people in order to solve mutual problems.

When discussing mutual problems that occur in intimate relationships, certain words and phrases often lead to more conflict than light. The author provides a useful list of words to use and words to avoid in what she calls the Word Patrol.

The reasons these otherwise wise and productive suggestions are likely to fail in people from more disturbed families with ongoing repetitive dysfunction relationship patterns is because they are quickly and easily overcome by powerful family reactions to the patient's new behavior. If your new behavior causes your mother to suddenly stick her head in an oven, metaphorically or literally speaking, or if everybody you know and care about comes down on you like a pack of hungry wolves with the strong message, "You're wrong, change back," most people will wilt and go back to the way they were. This process is particularly vicious in families that produce people with borderline personality disorders, as described in this post.

Instead of responding with less defensiveness and anger, dysfunctional family members can twist around what anyone says no matter what words are used or avoided. They can employ ambiguity and double messages to such a degree that the person who is trying to engage them in problem solving does not know what was actually meant or whether or not any issue was really resolved.

This does not mean that family members in families like these cannot be reached. They most definitely can be. But the process is way more difficult and intricate than the solutions described in this book might seem to imply.

Depression is a Symptom, Not a Psychiatric Disorder

Lately there have been a slew of articles about "depression" that seem to go out of their way to avoid discussing any specific psychiatric diagnosis listed in the DSM - instead strongly implying that "depression" is itself a disorder. These articles appear in the popular press, but, frighteningly, also in newsletters and newspapers for psychiatrists and psychologists. They explore such questions as "Do antidepressants work?" and "What is better for depression, drugs or cognitive behavioral therapy?"

These types of questions are completely meaningless. Depression is discussed as if it were a single phenomenon that, at best, exists on a continuum from "mild" to "moderate" to "severe." This type of wording is in fact completely ignorant, but does not necessarily reflect real ignorance. In many cases, different entities such as big Pharma have a vested interest in conflating several different psychiatric conditions.

In truth, "depression" is just a mood state, and as a symptom, it can be part of many different psychiatric disorders that are, despite some overlap in symptomatology, as different as night and day when it comes to their clinical presentations as well as their response to various treatments.

To name but a few actual diagnoses, there is major depression (both as part of unipolar and bipolar disorder), dysthymia, adjustment disorder with depression, depression due to a medical condition, and depression due to a substance. Medical conditions that can lead to depressive symptoms include hypothyroidism and some strokes. Substances that can do that include some steroids like prednisone and the "crash" that results when an acute cocaine high wears off.

Furthermore, "depression" as discussed in every day conversation can be a normal mood that is part of chronic unhappiness, or that occurs in response to grief at someone's death or due to any other loss or misfortune.

The most important diagnostic distinction for this discussion is between major or clinical depression and dysthymia. Although we don't know enough about the brain to know the exact causes of either one, and there is some overlap in symptomatology, they appear for the most part with very distinct clinical presentations, especially in their classic forms.

Dysthymia appears to be more of a psychological reaction, while major depression probably involves the more primitive part of the brain called the limbic system. The latter, unlike the former, is accompanied by a whole array of chronic, persistent (lasting all day every day for at least two weeks), and pervasive (coloring all aspects of the patient's mental life) physical symptoms - all at the same time - involving sleep, appetite, ability to experience pleasure, energy level and motivation, and concentration. Sufferers may have an unrelenting and constant sense of foreboding accompanied by inexplicable hopelessness and helplessness. We used to refer to these types of symptoms as vegetative symptoms.

Furthermore, someone in a major depressive disorder episode reacts completely differently to life's every day ups and downs than they do when they are not in the middle of such an episode. It's almost Jeckyl and Hyde territory.

These people stay depressed no matter what life events occur around them. They could literally win the lottery and would not really feel a whole lot better for more than a few minutes.

The most severe form of major depression is called melancholic depression. Most people who have never worked in a mental hospital have never seen a case, but the anti-psychiatry types who have not seen it blather on about depression incessantly as if they knew what they were talking about.

People with melancholic depression exhibit something called psychomotor retardation. People with this symptom move and think at a snail's pace.  It takes them longer to respond to any verbal interactions. They can even appear to have significantly impaired memory, although it is actually a more severe form of concentration impairment. That clinical picture is sometimes referred to as pseudodementia. 

You cannot spend more than an hour with such people without realizing that this condition has next to nothing in common with the type of "depression" people see in their everyday interactions with others, and that there is something seriously wrong with their brain functioning.

In severe major depression, doing any kind of psychotherapy (short of telling them, "take these pills") is a complete and utter waste of time. Sufferers literally do not have the mental wherewithal to deal with any kind of problem solving or other interactions with a therapist. And I say that as a major advocate of psychotherapy.

The symptom of depression in dysthymic disorder, on the other hand, rarely responds to antidepressant medication at all (although the drugs can be useful for other symptoms seen in patients with dysthymia such as panic attacks, obsessive ruminations, and the affective instability characteristic of borderline personality disorder). For these folks, psychotherapy is essential.

In my experience a very high percentage of the people who do drug and psychotherapy outcome studies, at least in adults, make almost no meaningful effort to differentiate dysthymia from major depression by: 1) Not spending any time making certain that patients understand the pervasiveness and persistence criteria that differentiate the symptoms of the two disorders; and by 2) Not taking a complete biopsychosocial history to distinguish psychological from limbic system factors.

All of the fancy biological research is not being complemented by good old fashioned clinical typing.

Furthermore, with the private Contract Research Organizations that do a lot of the studies, experimenters get paid only if they recruit a subject, and subjects get paid only if they get recruited - giving a financial incentive for everyone to exaggerate symptoms in order to qualify.

And people with suicidal ideation, comorbid (other, co-occurring) conditions, and significant personality pathology are excluded from studies. Those "exclusions" eliminate the vast major of subjects that have any of the psychiatric disorders in which depression is a symptom.

Garbage in, garbage out.

By the way, you can also have something called double depression. Such people are generally dysthymic but every so often can have a superimposed episode of major depression. So they have both conditions.

Once a major depressive episode starts to occur, it takes on a life of its own. However, being chronically unhappy, anxious, or stressed out may be risk factors for triggering a major depressive episode to begin with.  If you are genetically vulnerable to an episode of major depression, being chronically unhappy might make an episode more likely.

This is another reason why the question, "Should you treat these people with medications or therapy" is a really stupid question. It's a bit like asking, "Which treatment should people who have extensive, severe, cardiovascular disease get, bypass surgery or high blood pressure medication?" 

These treatments address completely different aspects of the disorder. In major depressive disorder, drugs should be used during the acute disorder, but psychotherapy should be given later to address personality  and relationship risk factors - in order to reduce the likelihood of subsequent episodes.

How Do You Know if You Should Try Treating Your Depression With Medication?

I have frequently blogged in this venue about the efficacy of antidepressants in “depression.”  I have pointed out that “depression” has a wide variety of different meanings, and that there are also several different syndromes of depressive disorders in the diagnostic manual, the DSM.  While there is considerable overlap in the symptoms of the various syndromes, some are far more likely to respond, and respond dramatically, to antidepressant medication than others.

I have also ranted against physicians who use “symptom checklists” or other self-report “tests” to make a diagnosis of depression, rather than use an extensive clinical interview.  The tests often say very little about whether a symptom a patient complains of is clinically significant for a certain diagnostic syndrome or not.  Aside from not looking at the psychosocial context in which the symptom occurs, the tests usually say very little about three important qualities of clinically significant symptoms – their pervasiveness, persistence, and whether or not they are pathological.  They also do not clearly show whether the symptoms all cluster together at the same times.

As I have pointed out several times, in order to make sure the patient is giving the doc an accurate and complete picture of their mood state, a good doctor must often ask one or even several follow up questions whenever a patient says “yes” or “no” in answer to a question about the presence of a symptom.

But how about a potential patient?  How does a non-professional know whether or not to even consult a physician about their mood state?  Why not just ignore it and see if it goes away?  Alternately, why not just go to a psychotherapist and handle it with psychotherapy alone?

That’s a very important question.  A similar question has recently been widely featured in the media in response to a proposed change in the DSM.  How does a patient or a doctor know when normal grief after the death of a loved one morphs into a clinical depression that would respond to medication?  The argument has mostly been about how long a doctor should wait after such a death before making a diagnosis of clinical depression, (major depressive disorder). 

While it is good that a doctor should not be overly hasty about making a diagnosis in this situation, in some genetically-prone individual, a stress of that severity can indeed trigger a major depressive disorder in a relatively short period of time.  Should that patient have to wait to be relieved of his or her suffering?  Certainly, any proposed “waiting period” specified in the DSM would have to be somewhat arbitrary.

To help patients figure out who to consult and when to consult a physician, a new self-report instrument is available that is significantly superior to the usual ones.  It is called the Post-Bereavement Phenomenology Inventory. It is meant to distinguish normal grief from major depression, but potentially it could also be used to distinguish major depression (likely to respond to meds) from another depressive syndrome, dysthymia (much less likely to respond to meds).

It was meant for physicians and not for patients to review for themselves, but even though it is better than most self-report instruments, IMO it should still not be used in place of a complete and wide-ranging clinical interview.  Context, prior history of major depressive disorders, family history of depression, and a whole host of factors need to also be considered.

But as a screening tool for patients, I think it might be helpful.  It uses a strategy called prototype matching.  This strategy focuses on the difference between depressive syndromes rather than the similarities.  The questions contain different descriptions of how each depressive symptom would present itself in classic cases of the two syndromes, and asks the patient, “[Which of the two descriptions] better describes how you have been feeling, thinking, or behaving for the past one to two months?”

Here it is.  I hope this will help potential patients decide whom to consult.  The first descriptions in each question are of the symptom presentation seen in major depression, while the second are of depressive symptoms that are less likely to respond to medication.  Of course, this is hardly foolproof, but generally the more you answer the questions one way or the other, the more likely you are to be experiencing one syndrome or the other. 


If someone's depression seems to conform mostly to the first prototype rather than the second, there are certain things that people often say to them that are both inappropriate and counterproductive.  An excellent list of such things can be found at http://www.medicalbillingandcoding.org/blog/11-things-you-should-never-say-to-someone-with-depression/

1.       I am filled with despair nearly all the time, and I almost always feel hopeless about the future.

versus

      I feel sadness a lot of the time, but I believe that eventually, things will get better.

2.      My sadness or depressed mood is near­ly constant, and it isn't improved by any positive events, activities, or people.

versus

       My sadness or depressed mood usually comes in "waves" or "pangs;' and there are events, activities, or people who help me feel better.

3.      When I am reminded of my loss (of a loved one, friend, job, etc), I feel nothing but pain, bitterness, or bad memories.

versus

    

       When I am reminded of my loss (of a loved one, friend, job, etc), I often feel intense grief or have painful memories, but sometimes I have good thoughts and pleasant memories. 

4.      I will probably never get back to feeling like my "old self" again.

versus

       Things are really tough now, but I'm hopeful that with time I will feel more like my "old self.”

5.      I feel like a worthless person who has done mostly bad things in life, and has let my friends, family, and loved ones down.

versus

       I feel like I'm basically a good person and that, in general, I have done my best for my friends, family, and loved ones.

6.      All I can think about lately is me and how miserable I feel; I hardly think about friends, family, or loved ones, ex­cept to blame myself for some failing.

  versus

       Even though I'm less social and out­going since my loss, I still think a lot about friends, family, and loved ones, often with good feelings about them.

7.      When friends or family call or visit and try to cheer me up, I don't feel anything or I may feel even worse.

   versus

       When friends or family call or visit and try to cheer me up, I usually "perk up" for a while and enjoy the social contact.

8.     I often have persistent thoughts or im­pulses about ending my life, and I often think I'd be better off dead.

     versus

     I sometimes feel like a part of me has been lost and I wish I could be reunited with the person or part of my life I am missing, but I still think life is worth living.

9.      Almost nothing that I used to like do­ing (reading, listening to music, sports, hobbies, etc) is of any comfort or con­solation to me anymore.

     versus

   The things that I have always liked do­ing (reading, listening to music, sports, hobbies,etc)  give me some comfort and consolation, at least temporarily.

10.  I feel "slowed down" inside, like my body and mind are stuck or frozen, and like time itself is standing still.

   versus

       My concentration isn't as good as usu­al, but my body and mind aren't slowed down, and time passes in the usual way.