What am I deciding on?

I was pointed to a decision aid. It’s about treatment options in depression. I think it’s very good. I also think that it requires a look from a linguist. Here it is.

First, why is it very good then? Well, it is very clear – both the structure and, importantly, the language. I think it is written in a way which will be accessible to just about all who read it. And it’s just one-page long. And yet, there are problems though. It’s the language.

My first problem is the shift between the introduction and the tool itself. I almost didn’t notice. Almost… So let’s have a look what the introduction says:

Use this decision aid to help you and your healthcare professional talk about different ways to treat your depression

No problem? No. So let’s have a look at the first cell in the tool:

This means no active treatment. You may see your clinician more often to check your symptoms, compare options and discuss your lifestyle and coping strategies.

The shift? Yes, exactly. As the introduction promises to help me decide about ‘my depression’, the tool itself tells me something about….’my symptoms’. I immediately ask: so what happened to my depression? Indeed the fourth cell in the top row says:

Selective Serotonin Reuptake Inhibitors (SSRIs) are medications that help with symptoms. The pills are usually taken once a day. Treatment usually lasts for 6 to 12 months

Let me ask again: what about my depression? After all you, the author, promised we would talk about my depression! Why do you want to talk about the symptoms?

Why don’t I like it? There are at least three reasons. First, I am yet to hear anyone who prefers talking about their symptoms. Every single person in depression I talked to talked about ‘depression’ and never split it into some parts which, to make matters worse, they had no control over. Basically, no, I don’t really have symptoms – I have depression. Or, better still, I feel crap, sad, bad, like staying in bed or like crying. No, definitely, don’t talk to me about my symptoms.

Second, whenever people tell me that medication is about symptoms, I want to ask whether I myself will feel better. Or is it only about the symptoms. I also want to ask whether it’s about all the symptoms at the same time, to the same extent. When medics talk about symptoms of depression (and other mental illnesses), I think, they tend to assume that it’s like in an army. All symptoms behave in the same way at all times…I mean, come on….

Third, what if my ‘symptoms’ don’t match yours, after all I don’t have to know the diagnostic criteria, you know. As I argued in my book on men’s depression, men I interviewed never talked about their mood, but always talked about their jobs. So will your medication help me in the case of the job which is important to me,  or is it only in the case of the mood which tends to be important to you?

So, that’s my first point. Perhaps a bit laboured.

Let me make my second point then. Let’s have a look at the sentence I already quoted:

Selective Serotonin Reuptake Inhibitors (SSRIs) are medications that help with symptoms. The pills are usually taken once a day. Treatment usually lasts for 6 to 12 months

For the life of me I cannot understand why you qualify the treatment (you use ‘usually’) and do not qualify the helping. Given the statistics you gave (with openness I applaud), don’t you think the sentence should be:

Selective Serotonin Reuptake Inhibitors (SSRIs) are medications that USUALLY help with symptoms.

There is quite a difference. Your sentence is in the third person (plural, which is irrelevant) and this is language at its most certain. This is like saying

That’s the way the world is.

God exists.

Admittedly, things are a bit more complicated, aren’t they? But there is more. Significantly, it is only in the case of SSRIs that the language is so certain. Let’s consider the other sentences on the help.

Talk therapy works by helping you solve problems and clarify your thoughts.

Exercise, healthy eating and visiting with friends can help with symptoms.

Linguistically, there is no claim about talk therapy helping at all, you focus only on the mechanism (granted, there is an implication, but I am interested in what you say, not imply). The sentence about exercise is quite tentative.And so, the only real solution, the solution which you offer with certainty, is the SSRIs. Do you really want to say this?

One final point on this. Quite interestingly, when you talk about side effects, you say:

SSRIs can cause side effects

That’s another shift. SSRIs simply help, but only can cause side effects. That’s a bit of a sleight of hand, in my opinion.

My third point is nit-picking, but I want to make it. Before I got interested in psy-things, whenever I heard of psychotherapy or ‘talk therapy’, I thought of Freud and psychoanalysis. I might be stupid, but I had no idea that there are about a zillion different kinds, types, subtypes and subsubtypes of psychotherapy. Speaking of ‘talk therapy’ as if it were homogeneous is unhelpful, I think. But it is nit-picking.

Let me finish like that. It’s the first time I thought a decision aid might be a good idea. Seriously. It’s clear, it tells me what I need to think about, it is actually quite helpful within a particular frame of thinking about mental illness. But such documents do not only have contents. They also have the linguistic form. And the linguistic form is not something trivial, especially when so much must said by so little.


  1. Dariusz,
    Thank you so much for your thoughtful feedback on the decision aid. Your suggestions are insightful and will go a long way to help improve the clarity of our tool – especially regarding the consistency of text and phrases used. Our use of the term ‘symptom’ rather than ‘depression’ was a conscious decision based on feedback from consumer interviews. There was a feeling that constantly reminding folks of their ‘depression’ may not be helpful. However, I concede we may have been too quick to come to this conclusion. I will reach out to more consumers and our patient partners to review that decision. Our decision on ‘talk-therapy’ was an attempt to simplify our tool. The evidence we used was from CBT and PST trials. The hope with this tool is that it can provide scaffolding to a conversation around depression treatment options, rather than an in-depth educational document.

    I’d be delighted to talk more about the language used and how best to improve it!

    Thanks again,

    1. Dariusz Galasinski

      Paul, thank you for your response.

      I had no doubt that your decisions were not haphazard. I was just trying to point out that your choices have consequence perhaps beyond what might have been considered. I also believe that linguistics might have a significant contribution in designing decision tools.

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