Tuesday, July 24, 2012

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

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


      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.

       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.

       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.


       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.


       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.


       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.


       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.


     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.


   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.


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



  1. Well, it's a start. And even GPs can implement it.

  2. Many factors can enhance the possibility of depression:

    1 Neglect. Past physical, sexual, or emotional misuse can cause despression symptoms later in lifestyle.
    2 Certain medication. For example, some medication used to treat high blood pressure, such as beta-blockers or reserpine, can enhance your possibility of despression symptoms.
    3 Issue. Depressive disorders may result from personal arguments or justifications with close family members or friends.
    4 Loss of lifestyle or a reduce. Disappointment or unhappiness from the loss of life or loss of a family member, though natural, can also enhance the possibility of despression symptoms.
    5 Inherited cosmetics. A ancestry of despression symptoms may enhance the risk. It's thought that despression symptoms is approved genetically from one creation to the next. The actual way this happens, though, is not known.
    6 Significant actions. Even positive actions such as starting a new job, completing, or planning a wedding, can cause to despression symptoms. So can moving, dropping a job or income, getting divided, or going.
    7 Other personal problems. Problems such as community privacy due to other psychological illnesses or being toss out of a family or community team can cause to despression symptoms.
    8 Serious illnesses. Sometimes despression symptoms coexists with a primary illness or is a respond to as well as.
    9 Content misuse. Nearly 30% of people with medication use problems also have major or despression symptoms.

  3. As the developer of the Post-Bereavement Phenomenology Inventory (PBPI), I very much appreciate Dr. Allen's bringing this instrument to the attention of the public. The actual article describing the PBPI was published originally in Psychiatric Times, which I would like to credit. One cautionary note: while I am hopeful the PBPI will prove useful in distinguishing the usual grief of bereavement from major depression, the PBPI has not yet been field tested for validity. Clinicians who wish to use it, of course, may feel free to do so, and I would welcome feedback as to its utility.

    Ronald Pies MD
    SUNY Upstate Medical University,
    Syracuse, NY

  4. Dr. Pies:

    Thanks for writing.

    I should have given you credit for the instrument and put in a link to the Psychiatric Times article: (

    Sorry about that! I usually do that; don't know what got into me.

  5. That's OK, Dr. Allen, credits are an easy thing to forget, with material on the internet. By the way, I had not intended the PBPI to guide treatment decisions, such as use of antidepressants. However, in principle, the PBPI could provide some guidance, in so far as "ordinary" grief associated with bereavement does not require medication--indeed, as I have emphasized in several venues, grief is not a "disorder" and does not require "treatment" (beyond "TLC" and tincture of time, in most cases).

    Finally, as you note, this preliminary instrument is no substitute for a thorough clinical evaluation of the patient--only an adjunct to it!

    Best regards,
    Ron Pies MD