Somewhere along the way, we decided that asking “Are you feeling better?” was enough.

But Chapter 4 of Chris Aiken’s Difficult-to-Treat Depression reminds us just how often we—and our patients—get that answer wrong.

Why?

Because depression distorts perception.

It dulls memory.

Flattens contrast.

Makes improvement feel invisible—or irrelevant.

So we keep adjusting meds based on fuzzy impressions… and wonder why we’re stuck.

But there’s good news here. Because one of the most reliable ways to improve outcomes doesn’t require new medications or advanced technology.

It just requires measuring symptoms at every visit.

Dr. Aiken cites a 6-month study where remission rates more than doubled—from 29% to 74%—when patients filled out rating scales and clinicians adjusted treatment accordingly.

Same medications. Just better feedback.

And yet, how many of us actually use these tools?

What struck me about this chapter is how grounded it is in clinical reality. Aiken doesn’t push elaborate systems—he offers simple tools (like his General Symptom Scale) and shows how to use them in the real flow of practice.

And he names something we don’t talk about enough:

Even when the data shows real progress, patients may not believe they’re getting better.

That’s not denial. That’s depression.

Aiken puts it this way:

“Patients may dismiss a clear pattern of improvement with comments like ‘I never know how to answer those rating scales… it’s just random numbers.’”

This is cognitive distortion in action—the same bias that skews memory and blunts hope.

And it’s exactly why measurement matters.

Because when we graph symptom scores together and point to slow, steady improvement, we’re not just sharing data—we’re helping patients see themselves more clearly.

This is the second post in my series reflecting on Difficult-to-Treat Depression—a book filled with tools you’ll actually use, in the room, with a patient, today.

Do you track symptoms consistently in your practice?

What gets in the way?

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▸ Follow me (Daniel Carlat, MD) for grounded reflections on psychiatry in real-world practice.