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On Fridays I will address a question related to depression and find the answer from an expert. If you have a question you want answered, please ask it on the combox of this post, and I’ll try my best to do some research and feature it in an upcoming Friday post.
One of the most common questions I hear is: How is depression different from sadness?
This question was recently addressed by Ronald Pies, M.D., a professor of psychiatry at Tufts and SUNY Upstate Medical Center in Syracuse, in an opinion piece published in the New York Times. You can get to the original article by clicking here. I have excerpted it below as the answer to this Friday’s question. Thanks to Jennifer of NYJLM blog for sending it to me.
Ronald Pies, M.D.: Let’s say a patient walks into my office and says he’s been feeling down for the past three weeks. A month ago, his fiancée left him for another man, and he feels there’s no point in going on. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.
Should I give him a diagnosis of clinical depression? Or is my patient merely experiencing what the 14th-century monk Thomas à Kempis called “the proper sorrows of the soul”? The answer is more complicated than some critics of psychiatric diagnosis think.
To these critics, psychiatry has medicalized normal sadness by failing to consider the social and emotional context in which people develop low mood — for example, after losing a job or experiencing the breakup of an important relationship. This diagnostic failure, the argument goes, has created a bogus epidemic of increasing depression.
In their recent book “The Loss of Sadness” (Oxford, 2007), Allan V. Horwitz and Jerome C. Wakefield assert that for thousands of years, symptoms of sadness that were “with cause” were separated from those that were “without cause.” Only the latter were viewed as mental disorders.
With the advent of modern diagnostic criteria, these authors argue, doctors were directed to ignore the context of the patient’s complaints and focus only on symptoms — poor appetite, insomnia, low energy, hopelessness and so on. The current criteria for major depression, they say, largely fail to distinguish between “abnormal” reactions caused by “internal dysfunction” and “normal sadness” brought on by external circumstances. And they blame vested interests — doctors, researchers, pharmaceutical companies — for fostering this bloated concept of depression.
But while this increasingly popular thesis contains a kernel of truth, it conceals a bushel basket of conceptual and scientific problems.
For one thing, if modern diagnostic criteria were converting mere sadness into clinical depression, we would expect the number of new cases of depression to be skyrocketing compared with rates in a period like the 1950s to the 1970s. But several new studies in the United States and Canada find that the incidence of serious depression has held relatively steady in recent decades.
Second, it may seem easy to determine that someone with depressive complaints is reacting to a loss that touched off the depression. Experienced clinicians know this is rarely the case.
Most of us can point to recent losses and disappointments in our lives, but it is not always clear that they are causally related to our becoming depressed. For example, a patient who had a stroke a month ago may appear tearful, lethargic and depressed. To critics, the so-called depression is just “normal sadness” in reaction to a terrible psychological blow. But strokes are also known to disrupt chemical pathways in the brain that directly affect mood.
What is the “real” trigger for this patient’s depression? Perhaps it is a combination of psychological and neurological factors. In short, the notion of “reacting” to adverse life events is complex and problematic.
Third, and perhaps most troubling, is the implication that a recent major loss makes it more likely that the person’s depressive symptoms will follow a benign and limited course, and therefore do not need medical treatment. This has never been demonstrated, to my knowledge, in any well-designed studies. And what has been demonstrated, in a study by Dr. Sidney Zisook, is that antidepressants may help patients with major depressive symptoms occurring just after the death of a loved one.
Yes, most psychiatrists would concede that in the space of a brief “managed care” appointment, it’s very hard to understand much about the context of the patient’s depressive complaints. And yes, under such conditions, some doctors are tempted to write that prescription for Prozac or Zoloft and move on to the next patient.
But the vexing issue of when bereavement or sadness becomes a disorder, and how it should be treated, requires much more study. Most psychiatrists believe that undertreatment of severe depression is a more pressing problem than overtreatment of “normal sadness.” Until solid research persuades me otherwise, I will most likely see people like my jilted patient as clinically depressed, not just “normally sad” — and I will provide him with whatever psychiatric treatment he needs to feel better.
To read more Beyond Blue, go to www.beliefnet.com/beyondblue, and to get to Group Beyond Blue, a support group at Beliefnet Community, click here.
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Therese J. Borchard writes the daily blog, Beyond Blue, on Beliefnet and is a regular contributor to the award-winning blog, World of Psychology, on Psych Central. Therese is the author of Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes and The Pocket Therapist: An Emotional Survival Kit. Subscribe to Beyond Blue, visit her website, or follow her on Twitter @thereseborchard.
Meet others on the journey in
Therese’s community group
Ask Therese to be your friend
Therese J. Borchard writes the daily blog, Beyond Blue, on Beliefnet and is a regular contributor to the award-winning blog, World of Psychology, on Psych Central. Therese is the author of Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes and The Pocket Therapist: An Emotional Survival Kit. Subscribe to Beyond Blue, visit her website, or follow her on Twitter @thereseborchard.
posted October 17, 2008 at 11:16 am
Therese I want to thank you and commend you for the broad scope you bring to this Blog. You provide personal experiences that helps people like me know I am not alone. These experiences provide practical, spiritual, and philosophical commentary and tools to help me and others in dealing with our illnesses. Articles such as this one also provide another facet to understanding and coping with our illnesses whatever it may be. Maybe this comment will end up in your self-esteem file.
Thank you!
posted October 17, 2008 at 3:09 pm
I really appreciate this article. I was diagnosed with clinical depression several years ago, and while it ebbs and flows, it has never fully left. I suppose if we looked at causation as a criteria, then my struggles caused by childhood abuse might be called sadness, rather than depression. The episode this week which stemmed from circumstances that mirrored abuse I suffered in grade school, well I guess that wouldn’t necessarily qualify as depression either.
I think that depression is one of the most difficult things to understand. That is what makes this article so important. Even so, I still wonder about it….why is it so devastating in some people and not in others….
posted October 17, 2008 at 5:26 pm
Therese:
Your compatriot in blogging Philip Dawdy (of Furious Seasons) is no fan of Dr. Pies, at all.
But I thought this particular column was common sense and excellent perspective.
posted October 17, 2008 at 7:39 pm
enjoyed the article as well as most things you write.i share alot of these with my freinds it helps give them a better understanding of depression.
posted October 18, 2008 at 12:44 pm
As one who suffered a no-cause bout of depression 8 yrs ago, treated w/ Paxil for 2 months and weaned off it, due to side effects, numbing me inside and out..this article helped..
I found out BETTER ways to pleasure myself…gardening, bike riding, hobbies , better work–jobs and then buisness
As of last year, last summer….I quitsmoking , and this was so liberating..yes I gained weight, and have some blahs here n there…nothing like I had 8 yrs ago…but this process has opened my eyes, my mind and health is so much better….
posted October 19, 2008 at 8:31 pm
Dear Beliefnet readers:
As the author of the NY Times piece on grief and depression, I appreciate your thoughts and comments. Unfortunately, a number of readers misunderstood my article as saying that “Grief is a disease”, or that it should always be treated with antidepressants. Not at all!
As I try to make clear in a much longer and more detailed piece on the PsychCentral website:
http://psychcentral.com/blog/index.php?Match=1&s=is%20grief%20a%20mental%20disorder
there are different kinds of grief–some are “healthy” and “productive”, others are unproductive and “corrosive”, veering over into clinical depression. Grief per se is not a disease, but in some instances, it may become one. When it does, professional treatment is appropriate, and this need not involve antidepressant medication–though in some cases, these medications may be helpful. I would encourage interested readers to peruse the longer essay on the Psychcentral website. –Sincerely, Ronald Pies MD
posted October 21, 2008 at 9:59 am
Since I have trouble navigating here and am afraid I may not be able to find my way back to this page I am going to post my comments before going on to read the other suggested articles.
It would seem to me to be a simple thing to realize that people who find their way to professional help are suffering more than “situational depression” and therefore need the help they seek. While I realize there may be those who would abuse the system for drugs or even for attention and I think it would be up to the professionals discretion to weed those out, it would seem to me that someone who is unable to deal with symptoms, find the depressive symptoms overwhelming,should indeed be considered to have some internal dysfunction and be treated seriously by the psychiatric and/or medical community. Indeed weather or not the symptoms are triggered by a situation or by physical dysfunction the patient is in need of treatment.
posted October 21, 2008 at 10:01 am
Thanks a lot – I posted a whole paragraph and it disappeared because I forgot to put in my name. There is no way I can reproduce it now.
posted October 21, 2008 at 11:43 am
WOw! proper sorrow of the soul. I do see a pattern especially of the saddness does not go away or if we think we can move forward with this saddness straped to our backs.
Sorrow of the soul makes so much sense when we are talking about a broken heart or loss of a loved one. The sorrow then eats away at self esteem. While we try to fight off the sorrow at least for me I did the whole deeper or that the sorrow grows and a solution seem so far away.
OK I am rambling but sorrow of the soul means it hurts that deep.
Bob
posted October 21, 2008 at 12:10 pm
Situational depression can be as heart-rending as clinical depression and should be treated by a professional and in most cases with anti-depressants for awhile. The difference however is that one does “recover” from situational depression while clinical depression is the lack of any or adequate quantities of chemicals within the sufferer and there are not “yet” any discovered means of putting those chemicals into a person other than the temporary effect of anti-depressants. By temporary I mean that the medication must be taken regularly and for long periods of time if not, as with me, for the remainder of my lifetime.
My sister understandably suffered about 6 months of situational depression when she discovered her husband had maintained a mistress for as long as they had been married and wanted to divorce her to move the mistress into their home. I felt her pain- and was thrilled when she pulled out of it.
However, my body does not produce seratonin. I cannot pull out of this. Yet she continually tells me I am weak and should just “get over it already”. As I cannot do that- I have chosen to “get over” having any form of communication with her. I am not weak- I am quite strong as I have successfully NOT committed suicide as has been an almost daily thought upon waking up and which I know to be my disease talking. I have found peace in my life and even the joy each day offers if that joy is only that I have been considered disabled by S/S so do not HAVE to force myself out of bed if staying in is the safer, more comforting option.
A diagnosis of clinical depression need not be made in order for a qualified and knowledgeable psychiatrist to prescribe medication and therapy for a patient who is extremely sad due to life events.
posted October 21, 2008 at 12:13 pm
hi i have depression,among other things but i have tried alot of meds and nothing works my dr. has put me on alot of meds paxil didn’t work made me think of suiced..anyway there are days when i’m more depressed. i also have alot of pain..keep on track, i have tried alot of meds.i just give up on hope..i’m on ssi and i don’t think that the dr.’s really care they don’t take the time to listen,my dr, recently left the office.and the one i have now doesn’t listen either, i guess cause i have medical and they have a lot of people on there case load,if i was a dr i would listen more,not over work my self.anyway thanks
posted October 21, 2008 at 12:26 pm
I suffer from “chronic grief” as I attempt to raise a 13 year autistic son. I agree with Bob – it is a deep sorrow of the soul. I am on Effexor for depression which stems from this chronic grief. Every day brings a new challenge for my son & myself, trying to cope with the current challenge. My grief will not go away, some days are just easier to cope than others.
Gloria
posted October 21, 2008 at 12:29 pm
Your article makes perfect sense. I have been struggling with various forms of depression most of my life. I came from an abusive home, and the ramifacations from that followed me into my adult life. I suffered from the normal life ups and downs and after having 4 children of my own and then adopting my nephew, bc of my sister’s sudden death, and the succession of the falling apart of the rest of my exteded family, I felt I was just grieving. Then that grief turned to not being able to get out of bed, not eating, not bathing, and just total loss of being able to care for myself. I was convinced that it was just normal grieving, but after 10 years of it, and then panic and anxiety started to become my everyday life, I wound up in the hospital. I thought I was having a stroke, but it turned out to be an emotional breakdown. I’ve been on an antidepressent for 2 years, and feel better than I have my entire life. (I’m 46) Depression ran on both sides of my family, as well as suicides have happened on both sides. I didn’t see myself as sick as the others. I thought I could fix myself. As my life progressed and bad things happened, what would be normal situational grief, piled on and piled on, till I broke. I wish I would have gotten help sooner, for myself and my families sake. I hope that this can help someone else struggling as I did, to get the help they need. When normal grief or sadness doesn’t pass in a reasonable amount of time ~ get help!
posted October 21, 2008 at 12:33 pm
I hurt my back rather saverly at work and kept working for six months untell I just couldn’t hardly stand it anymore.I love my job and care a great deal for my boss and the small family owned company I work for and was afraid to put my job and family at risk but I finaly had to go through with the work comp thing and the threats by my employers outside H.R. department of termanation and investagation of posible crimnal behavor that would be delt with as a felony and it scared me so bad that I just freaked out. so I got a lawyer and it all has gotin to be a real big mess. The thing is I began having nightmares about everything from being homeless to lossing my family and being put in prison and the list go’s on and on untell it has goti’n so bad I can’t sleep more than a few minutes at a time and sweat all night ,use no covers and my skin fell’s like it is burning kind of like how your foot feels when it is asleep but it is my face, neck, chest and arms.They cut off my healthcare benifits and the man with HR has called me up at home and told me he has been biulding a case aginst me and is not looking forwared to what he is going to do to me and he will have investagators whatching me so i’d better be for real. I am a 51 year old male very gental in nature.I know I have done nothing wrong but the fear and angsiatiy is very real.It has taken it’s toll on me for about six months untell now I just can’t seem to realy care about life and all its wonderful things anymore. I have no emotion about moveis (us to love them so much)I nolonger care if my cars are dirty and cars and hot rods have been a hobbie all my life and a great passion of mine I have played music since I was 6 years old almost everday but I have just stoped and nolonger have any desire to play in fact I almost can’t staned to here music or the radio and have quit listning to it completly. I have allways been a very sexual man and now I only hope that my beautiful wife dosn’t get the Idea becasue I am so not interested at all although my love for her is not deminished I just am nolonger interested in anything to do with sex or love and romance not even when a great pair of legs in the mall walk by and ….nothing all my zest for life is just gone out of know where and I just can’t even seem to find the energy to fake it for my loved ones sake anymore. it realy just knowlonger feals worth it Their is so much more but it is to much to write their was grief but after so long it feels as if depression has taken over my every emotion untell day to day conversation and function are just to much to deal with I just hide in my house won’t go outside and don’t want to answer the phone or speak to anyone anymore
posted October 21, 2008 at 12:45 pm
In the many years of having a mother who has been diagnosed as bipolar I have discovered an important difference between sadness and mental illness. Anger. The unanswered anger whether it stems from social, economic, even the biological. Grieving for a loved one makes a person sad. Grieving for a “loved” one that you wanted to get away from for 40 years, the anger gets unleashed onto family members who do not know how to help. And then the “mental health” industry gets involved, so now you have a “drugged” angry person so that the rest of the world can live with them. Then comes the black side of the drugs. The health insurance denials. The exhorbitant hospital, pharmacy, counseling bills, which go to the family member(s) to pay. Anger, how do we relieve people of anger?
posted October 21, 2008 at 1:14 pm
Hello Everyone,
I was touch with everyone’s honest comments and intrigued by this article. I am a Personal Process Therapist, and we live in a society, where we haven’t been taught how to feel our feelings, which are suppressed and escalate into Physical pain and disease.. Disease is merely DIS-EASE, lack of flow and ease in our lives. So when we resist our feelings, due to shame,guilt or judgement, we develope more serious illnesses, both physical and emotional. I suggest finding a therapist that is trained to support and nurture you to allow you to feel your feelings, and you will live a drug free, pain fee life…
posted October 21, 2008 at 1:27 pm
So many psychiatrists love to commit medical insurance fraud and are very motivated by the money that they do not even care that it is sadness from losses in life, but instead put labels onto a person, put them onto medications and put people away in psychiatric wards when these things are medically unneccessary. Psychiatrists make large amounts of money by doing it and they do not even care how badly it affects the persons reputation, and how it causes the person not to be able to get and keep a job, as well as getting a person kicked out from their home, and made to be homeless and having to live in a drop in center, shelter on account of it. This is unfair, evil, cruel, inhumane, abusive, wicked and very satanistic. Psychiatrists often misdiagnose and prescribe medications for ailments that do not even exist within the person, just so that they get the monetary gains and profit by it all. It is more to their benefit. It is wrongs done against people who fall victim to it. The fraud that is committed due to psychiatrists deceptions, trickery and deceit, to make a person feel as if there is something wrong with them when there really is not, which is very corrupt. This is unfortunately the very type of society in which we live in. When money talks, corruption walks.
posted October 21, 2008 at 1:29 pm
I have been depressed since chidhood,Starting with seeing faces as a child.To this day,I still have those faces.Now I am fifty yrs old.Suffer from depression,I am on Seraquel to block the faces,in order to go to sleep at night.always thinking it will never stop.Is there a reason,for these faces.especially the repeaters that come to me.Always feel others pain,then it seems that I already know what to do for them.When I am able to this,I feel great,but then all over again,I feel the sadness,deep in my heart.At times I wish that I had answers for me.
posted October 21, 2008 at 5:57 pm
I have suffered from depression every since i remember. I was always sad. The 2 people who mattered most to me were gone. My parents abanded me as well as my siblings when i was 10. Then i guessed they abanded each other idk. All i know was this empty type of feeling , a hole that i tried to fill with food, sex, unhealthly relationships, and drugs. Pot is my drug of choose.
It felt great at the time , i did have some good times. But the reackage it left, just gets me even more depressed.
I also suffer from panic attacks, and have been dionosed with PTS>
so I AM A hot mess. talking about anger , i get so angry at times i see red, not good….
I did have some goood clean time, but the panic attacks pluged my being, i went to a dr. who perscribed zanex, i evenually got hooked on them. they worked a little too well, and way too easy to get.
But they soon became the center of my life.
I went into a Rehab partcically to get away from an abusive relationship, and as well to get off drugs. and instead of putting me in relapse unit, i end up in the dualie unit. I was soooooo drugged up i couldnt function when i got home, yes, i didnt have any major panic attacks but i couldnt funtion? I was self employed.and am now unemployed, with no income , i am now just trying to pick up the peices, i have gotten off that medication on my own, but i did go back to smoking…. It is what it is. all i can say is i have made it this far , Gods not going to drop me now….. Let’s just be good to ourselves.
posted October 21, 2008 at 6:35 pm
I have suffered from depression for many years and I see my son suffering depression. I have not been on medication for years and self talk myself through my problems in my life. I had a very sad upbringing where we were taken from my parents, i came from a very large family. I tried to kill myself and fell pregant to my first son. which to me was a blessing. I was a single mother to him for eight years. When he was three years old we lost my brother who was a father figure to my son. My son found him hanging from a tree. And has never been the same since, he has behavioural problem and has try to take his life twice this year. The mental health doctors just say my son is behavioural. To me I see the traits and know it’s more than just being naughty he is very depressed and the saddest thing is i have try with many doctors, and couselling and with my own knowelege and experience with it feel that i am a lost with my own son. I just hope that he finds the spot within himself that says enough is enough and let me get out of this. with out him taking his own life. I still suffer depression and seeing my son go through it and not knowing what to do for him is the hardest thing i face eachday. I feel i gave my son this sickness because i was very depressed when i was pregant with him. But i see my son as my saviour because if it wasn’t for being pregant and have the resonablities of motherhood I can say I would not be here today. So God Bless His Soul. I do have a beautiful family today my saviour, my star, and my joy are my children and my honeygarlin’ So I am one of those lucky ones who who had a second change to deal with DEPRESSION.
posted October 21, 2008 at 7:20 pm
I recommend three books for you to read by Doreen Virtue: “Divine Guidance”, “Healing With The Angels”, and “Realms of the Earth Angels”. Graze through “Realms of the Earth Angels” (small book) first and you will know that you are not alone in your experiences. I cried when I found that book. I know now why I have felt different from everyone else my whole life. You have an amazing and special gift Lorraine!!
posted October 21, 2008 at 8:50 pm
This is such a simple debate that it is amazing to me that so many other people have not caught onto it.Sadness occurs when an event,such as the death of a family member, or even a beloved pet,passes away.That sadness is normal.Sadness occurs when a family member is dying and there is nothing that other family members can do to stop the death from happening. Chronic clinical depression has happened when the person who is suffering from the depression,looks around in their life and cannot find a reason for the depression.They are depressed for no apparent reason at all.It occurs when there is a chemical imbalance in their brains that simply cannot cope normally with stress.That is when prescription drugs such as Prozac and Lexapro help.Those drugs compenstate for that chemical imbalance.I wish people who have never had to cope with chronic clinical depression,would stop saying that these people should just “snap out of it” or just “re-arrange the furniture”,and then the people who are suffering from depression would “get over it.” Fifteen years ago,my doctors switched me from Prozac to Lexapro and my life has been so much better.Yes,I still experience stress (like the death of my mother in 1997) but I know now that whatever life throws at me,I can handle.But clinical major depression is a very real illness,just as cancer is.I thank God that I was able to find a doctor who truly understood what I was going through and was able to help.
posted October 22, 2008 at 1:44 am
To be very honest, when i first started reading your comment i thought to myself ,lorraine, how different or unusual but i remembered back to when i was first hospitalized for what was thought to be depression but turned to be a different diagnosis than just depression. And i now recall also seeing faces too. Along w/ the faces was their voice. I mean it sounded just like the voice of the face i was seeing if i knew the person whose face i was seeing. it went right along with the face. This has at times helped me to listen in on whats said by the face, but has thrown me offtrack at least some at times too. so normally i try to ignore the voices and faces if at all possible if they are present .
The drs. and nurses to me anyway acted as if they had never heard of this before so i sometimes felt it was unusual. Now, perhaps i think it was a special gift from reading the response to you to read the books about angels. wow!! Like i was saying earlier i have been helped to move “mountains” of heartache but sometimes it has thrown me off too. So i guess maybe i need to know when to and when not to listen or pay attention to the faces i see still at times.
i was told one time,the voice(s) may be trying to truly help the person who hears them make their life better or to straighten myself out to heal or make sense of it all. i hope that makes sense and hope i didnt misqoute the person who told me that, but what they said helped me and gave me great comfort.
so i may be looking up those books too so apparentely im not alone in this and neither are you!!! May God Bless You.
posted October 22, 2008 at 6:52 am
This past Mar of 2008, my fiance of twelve years passed away suddenly on Easter Sunday. He was 49 and I am 44. He was my support, my confidant, my rock. He was my everything. I miss him so much and the tears have not lessened with time. I feel so lonely and alone. My son is in jail and it seems that he will be going to prison for 14 yeara. He is my youndest son, 20 years old. 14 years is such a long time for him to be away from us that love him. I don’t think that I will be able to stand losing him when I am still grieving for my significant other. How long is it supposed to hurt when someone you love dies unexpectedly? How long til you feel like living again? I am so lost without the man that I loved for the last 12 years. I have so many unanswered questions that I will never get answers to. I am not happy and I am only tolerating life praying for the fog to lift so I can see the clouds and the bright blue sky again. What can I do that will help me heal after this loss?
posted October 22, 2008 at 10:21 am
Here is a suggestion that has positive results: 1) Make a list of your chores or tasks for the day. 2) FOCUS ON THE PRESENT MOMENT(yoga is very helpful). Keep your thoughts on NOW. This is TRUE FAITH in THE POWER WITHIN. Your POWER WITHIN will not let you down. Try it and feel good again. Read about your POWER WITHIN, find out who you really are.
posted October 31, 2008 at 7:58 pm
I noted earlier my appreciation for those who read and commented on my NY Times article. Unfortunately, many readers misunderstood the message I was trying to send. I want to urge members of Beliefnet to take a look at my longer and more detailed article on Grief vs. Depression, posted at:
http://psychcentral.com/blog/archives/2008/10/04/is-grief-a-mental-disorder-no-but-it-may-become-one/
Best regards, Ronald Pies MD