A Case of Major Depression: Some Philosophical Problems in

Everyday Clinical Practice

Paul B. Lieberman

Philosophy, Psychiatry, & Psychology, Volume 24, Number 3, September

2017, pp. 215-218 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/ppp.2017.0028

For additional information about this article

https://muse.jhu.edu/article/669741

Access provided by University of South Dakota (20 Dec 2018 15:05 GMT)
 A Case of Major
Depression
Some Philosophical
Problems in Everyday
Clinical Practice
Keywords: Diagnosis, psychiatric ethics, therapeutic
alliance
A
fter the publication of third edition
of the Diagnostic and Statistical Manual
of Mental Disorders (DSM III) in 1980,
psychiatry no longer characterized psychological
problems as ‘reactions,’ which seemed to assume
unproven psychoanalytically derived explanations,
and referred to them instead as ‘disorders,’ which,
it was thought, could be identified phenomeno-
logically and without theoretical ‘presuppositions.’
Since then, psychiatrists have typically made
diagnoses without reflecting on the fact that any
categorization, including psychiatric diagnosis,
exists within a framework of beliefs and prac-
tices and will, therefore, have implications and
consequences. The fact of making a diagnosis,
the act of doing so, the nature of the diagnosis,
and the various ways the diagnosis can be used
all have implications and consequences whose
importance cannot often be clearly discerned.
Such effects are frequently a complex mixture
of clinical, conceptual, ethical, and sociological
features as Dr. Kayali Browne (Browne, 2017) has
© 2017 by Johns Hopkins University Press
Paul B. Lieberman
suggested. Yet the busy and usually philosophically
untrained clinician is poorly situated to address
these vexing matters during the routine course of
his or her practice.
As the following case tries to illustrate, making
even the most common clinical diagnosis, that
of major depression, can immediately immerse
the clinician in a nest of philosophical problems.
Philosophy, like therapy, can be helpful in clarify-
ing and sorting things out, but only after the need
for clarification is recognized and appreciated will
either treatment begin.
Mr. H was a 54-year-old married man who
lived with his third wife and her two children, and
worked as a school bus driver. He was referred
by his endocrinologist to Dr. S, a psychiatrist, for
symptoms of depression.
Mr. H presented reluctantly to Dr. S’s office,
but then provided a clear history of major depres-
sion that had developed over the past year. He
noted that nothing gave him pleasure anymore.
He had trouble getting up for work, but felt lost
and unfocused on the weekends. He rarely slept
through the night, was tired most days, picked at
his food, and lost weight. Usually outgoing and
extroverted, he now turned down most social
216  ■  PPP / Vol. 24, No. 3 / September 2017
invitations and, when he did see friends, they
noticed that he seemed ‘glum’ and had little to
say. He was irritable with his family, but anxious
when by himself. So unbearable was his mood
that he seriously considered buying a gun and
shooting himself.
As Mr. H and Dr. S talked, it became clear that
these changes had started about a year before,
when Mr. H had learned that his wife was having
an affair. They had been married for 3 years; it was
her second marriage, his third. Mr. H’s first two
marriages had ended in divorces after both wives
had left him for other men. This time had seemed
to be different and Mr. H, who had no children
of his own and very much wanted a family, was
happy to be able to support his new wife (who
did not work) and her children. He told Dr. S that
he had felt ‘less than’ since childhood and being
able to help and to care for others made him feel
worthwhile and important. Now all he felt was
overwhelming failure at some moments, impotent
rage at others.
Mr. H had type 2 diabetes, which had been well-
controlled. But he had begun to worry about his
vision; it seemed blurry and unclear. He became
concerned that he could no longer drive the school
bus safely, recalled a few ‘near-miss’ accidents and
began to take time from work because of anxiety.
Like his marriage and being ‘head of the house-
hold,’ driving the bus was very important to Mr.
H. The responsibility he felt for the children, his
spotless record, and the appreciation of parents
and the affection of his small passengers all con-
tributed to a well-deserved sense of pride and the
knowledge that he was contributing meaningfully
to his community. He could not imagine doing
anything else.
But now he had started to feel incompetent as
a driver and frightened that he might accidentally
harm the children or someone else. This fear was
so great that he decided to stop work and was ap-
plying for disability. By the time he saw Dr. S, Mr.
H had been home for several months, completing
the application, using his temporary disability
benefit, but feeling more and more depressed,
anxious, and useless.
Mr. H’s endocrinologist did not think the
severity of his diabetes warranted applying for
disability. His eye examination showed minimal
changes and his vision was within normal limits.
Still, Mr. H no longer drove with confidence or
assurance and cited the ‘near-miss’ incidents as
‘proof’ that “I can’t drive anymore.”
When he saw Dr. S, Mr. H told him that he
was applying for disability and asked if Dr. S
would ‘support him’ on the basis of depression.
After only one visit, Dr. S felt uncertain and told
Mr. H that he did not know him well enough to
make this judgment. But after a few visits, during
which Mr. H began an antidepressant medication
and a cognitive-behavioral form of therapy that
emphasized becoming more active and ‘assertive’
and learning to ‘challenge negative assumptions’
he held about himself and his world, Mr. H raised
the question again. His temporary disability was
running out. Would Dr. S ‘back him’ in applying
for permanent disability benefits?
There was no doubt in Dr. S’s mind that Mr. H
was disabled. He could not work or drive safely
at this point. But Dr. S also believed that this dis-
ability was, in large part, caused by the depres-
sion. The inability to drive was ‘psychological’ not
‘physical,’ and, as such, amenable to psychiatric
treatment. In fact, Mr. H’s conviction that he was
disabled was, itself, likely to be a symptom of the
depression and, if that were so, Dr. S wondered,
should he ‘go along’ with it, at all? He would not,
of course, agree with other ‘depressive’ automatic
thoughts or ‘schemata,’ (e.g., Mr. H’s thought that
he was ‘a loser’ and of no value because of his
self-described ‘failures,’ or even his preoccupation
that he might inadvertently hurt the children or
others)—would not reinforce or validate them—so
why agree with the judgment of disability?
In addition, the fact that Mr. H now thought
that his situation was more or less hopeless might
well interfere with his acceptance of and par-
ticipation in treatment, and therefore make the
treatment less effective. If Dr. S agreed with Mr.
H, he would not only be validating a depressive,
inaccurate symptom of the disorder, he might also
be undermining treatment for it.
Dr. S also wondered what would happen to Mr.
H if he were approved for disability. For many
people, Dr. S knew, that ‘benefit’ consigned them to
a life of limited productivity and less gratification.

Dr. S also knew that ‘behavioral activation’ (where
patients are encouraged to engage in productive or
gratifying life activities) was an effective treatment
for depression. Financially secure, but having little
to do, might actually make Mr. H worse.
Yet that is not at all how Mr. H saw things.
He was worried he would end up on the street
(another depressive thought?) and seemed to have
made up his mind that disability was his best, in-
deed, his only, option. Dr. S was sympathetic: He
wanted to agree with Mr. H both because he felt
that was generally the ‘right’ thing to do (Moran,
2005) and also because he knew that a strong
‘therapeutic alliance’ was essential to any effective
treatment—including the treatment of depression.
If Mr. H thought that Dr. S did not agree with him,
that ‘rupture in treatment’ could also interfere
with the treatment itself and contribute to Mr.
H’s remaining disabled. So should Dr. S support
Mr. H’s application, not believing in it, himself?
Dr. S worried most about what would be best
for Mr. H: Would supporting his application be
helpful or make him worse? Would not supporting
it ultimately be empowering or alarm him further?
But Dr. S also recalled conversations with other
colleagues and friends: What about the cost to
‘society’ if Mr. H did receive disability? In medical
school, Dr. S. had been taught that a physician’s
obligation was always to do the best she could
for each individual patient, solely on the basis of
that person’s needs and the ‘clinical indications’
in the case. (Fried, 1974) Calculations in terms of
the ‘cost to society’ were thought irrelevant and
unethical, except in simple situations where two
equally effective alternatives had radically differ-
ent costs. Now, he knew, doctors were confronted
daily by considerations of cost and, in a change
from what he had learned and assimilated, re-
minded daily that they should be taking cost into
account in their medical decisions. Dr. S. knew
that he was a ‘gatekeeper’ for medical treatment
and for disability, and he felt that he was correctly
positioned to be one, because he knew Mr. H. best
of all. Yet in this position, he also felt confused
and uncertain how, or even whether, to try to
balance his obligations to Mr. H’s clinical needs
against obligations to ‘larger, societal’ interests.
As a psychiatrist who, of course, also had his
Lieberman / Case of Major Depression  ■ 217
own political opinions. Dr. S wondered if he could
appropriately balance them. As a physician who
had trained 25 years previously, he wondered if
he should try to do so.
(For a moment, another thought assailed Dr. S:
What about the interests of the children in the bus?
What was his obligation to them? He managed to
put this worry aside by reassuring himself that Mr.
H was too good a driver and too conscientious a
person ever to endanger anyone. But he was not
entirely satisfied with that conclusion.)
Dr. S explained these problems to Mr. H. ‘Yes,’
he told him, ‘you are disabled now, but your dis-
ability is very likely a part of your depression and,
with treatment, should significantly improve. I
understand you are convinced that you are dis-
abled but, though I respect and understand how
you feel, I see things differently: Your fears and
convictions are colored strongly by your mood.
With treatment, in a few weeks or months, you
are very likely going to feel differently and would
make different decisions about work and disabil-
ity, but by then it may be too late because we know
that there are real dangers to your mental health
from being on disability. Being on disability could
actually make your depression worse.’ (He did not
share his worries about the costs to society or the
safety of the children, believing that they would
only inflame the situation.)
Mr. H listened patiently to Dr. S. He thought Dr.
S an honest man and a caring physician, but also
simply unable to ‘see things’ from Mr. H’s point
of view. Mr. H. did not think treatment would
solve the problem or solve it quickly enough, the
bills were coming in, and he had started to feel
panicky. The ‘objective’ considerations that Dr.
S. brought forth had no impact. Mr. H continued
to press his case.
And Dr. S had to admit that there seemed to
be a lot of truth in what Mr. H had to say. Dr. S,
although he hoped the treatment would work,
knew that there were certainly no guarantees. Mul-
tiple antidepressant trials were often necessary,
remission was frequently partial, psychotherapy
required time, and, as Dr. S had already noted,
motivation and commitment that Mr. H, who was
facing bankruptcy and eviction, seemed to lack at
this point. Would it be right to support Mr. H’s
218  ■  PPP / Vol. 24, No. 3 / September 2017
application now, try to engage him in treatment
(the urgency for which might, or might not, drop
when Mr. H began to receive disability payments)
and hope that, someday, the process could be re-
versed and Mr. H return to being a functioning,
working member of society? Dr. S was not sure.
This was the healthiest and ‘easiest’ patient he
would see that day.
References
Browne, T. K. (2017). A role for philosophers, sociolo-
gists and bioethicists in revising the DSM. Philoso-
phy, Psychiatry & Psychology, 24, 3, 187.
Fried, C. (1974). Human experimentation in medicine.
New York: Elsevier.
Moran, R. (2005). Getting told and being believed.
Philosophers’ Imprint, 5, 1–29.