# Depression versus Sadness



## David Baxter PhD (Oct 29, 2012)

*Redefining Depression as Mere Sadness*
By RONALD PIES, M.D. in _The New York Times_
September 15, 2008 

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 fianc?e 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 ?  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.  

_Ronald Pies is a professor of psychiatry at Tufts and SUNY Upstate Medical Center in Syracuse._


----------



## Darkside (Nov 22, 2012)

> 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.



I'm not convinced this is true. It may be that by prescribing anti-depressants we are short-circuiting the brain by not allowing people to activate the spiritual healing process. We may also be covering up or disguising the underlying problems (trauma, abuse, co-dependency, etc) causing depression which only appears to be "without cause." 

In the Prozac age we don't much allow for "proper sadness of the soul." We don't give people time to mourn, grieve and heal and we don't recognize that everyone is different and may recover at different rates. We want "instant" feel better, and demand that people return to being a productive member of society. We also have little time for reparations, atonement, making amends and allowing ourselves to feel guilt and sadness. These things have a purpose, but modern man wants instant gratification. I won't say we have lost the capacity for but I think we have lost patience.


----------



## David Baxter PhD (Nov 22, 2012)

Darkside said:


> I'm not convinced this is true. It may be that by prescribing anti-depressants we are short-circuiting the brain by not allowing people to activate the spiritual healing process. We may also be covering up or disguising the underlying problems (trauma, abuse, co-dependency, etc) causing depression which only appears to be "without cause."
> 
> In the Prozac age we don't much allow for "proper sadness of the soul." We don't give people time to mourn, grieve and heal and we don't recognize that everyone is different and may recover at different rates. We want "instant" feel better, and demand that people return to being a productive member of society. We also have little time for reparations, atonement, making amends and allowing ourselves to feel guilt and sadness. These things have a purpose, but modern man wants instant gratification. I won't say we have lost the capacity for but I think we have lost patience.



I must disagree. Grief and depression are not the same thing, as the article correctly states. But SSRI medications can assist the process of grieving,loss, or persistent sadness (a) when there is concomitant depression or dysthymia, and/or (b) when there is concomitant anxiety, and/or (c) where there is concomitant or reactive insomnia. 

The idea that these medications dull emotion reactions or prevent the experience of emotion is a common misconception but it is simply not true. If an individual is experiencing a dulling of emotional experience that is truly medication-based, that person is either on the wrong medication or the dose is too high.

The purpose of psychotropic medications is to help the individual better cope with or manage symptoms, and to facilitate processing emotional content.

By the way, I know this not only from my work with clients but also from personal experience.


----------



## Darkside (Nov 22, 2012)

Perhaps. I'm not a doctor and my beliefs are shaped by my own experiences. Something just tells me that we shouldn't be too quick to take medicine to recover from grief. I think the body has natural healing mechanisms and so does the mind - and the soul; and one can impact the other.

When psychotherapy and psychiatry split (psychiatrists rarely do therapy any longer) I think it created a divide between the physical/biological and the thoughts/feelings model of human behavior. My brother relied exclusively on drugs and refused psychotherapy. He believed all "bad feelings" were the result of defective brain chemistry. He lived his last 5 years in the search for the right combination of drugs so he would never feel "bad" again.


----------



## David Baxter PhD (Nov 22, 2012)

Darkside said:


> When psychotherapy and psychiatry split (psychiatrists rarely do therapy any longer) I think it created a divide between the physical/biological and the thoughts/feelings model of human behavior.



Not necessarily. I think the ideal ment\l health practitioner is one who is both biologically/physiologically  and psychologically informed.



Darkside said:


> My brother relied exclusively on drugs and refused psychotherapy. He believed all "bad feelings" were the result of defective brain chemistry. He lived his last 5 years in the search for the right combination of drugs so he would never feel "bad" again.



Obviously that was a grave error. All of the research on recovery from depression, anxiety disorders, etc., etc., has repeatedly confirmed that the best (i.e. most effective) treatment for most people is a combination of appropriate medication and appropriate psychotherapy, whether measured in terms of response to treatment or resistance to relapse. Using one or the other alone is significantly less effective.


----------



## Darkside (Nov 22, 2012)

I should have said it created a false dichotomy. I agree that the best treatment model treats both. It is just that many people see a therapist in one building and practice, and then make a separate appointment with a psychiatrist in another building and practice to have their medicines checked. This creates a split between treating the body and treating the soul.

Therapists can't prescribe medicine and psychiatrists don't do therapy.

For awhile many psychiatrists kept a practice with therapists and they collaborated. Some still do and I wish that was more common. I doubt we will ever return to a time when psychiatrists do therapy.


----------



## David Baxter PhD (Nov 22, 2012)

Darkside said:


> I should have said it created a false dichotomy. I agree that the best treatment model treats both. It is just that many people see a theriapist in one building and practice, and then make a separate appointment with a psychiatrist in another building and practice to have their medicines checked. This creates a split between treating the body and treating the soul.



It need not if there is communication between therapist and psychiatrist. I agree that should be more common because where it exists, with the permission of the patient of course, the patient benefits.

Therapists can't prescribe medicine and psychiatrists don't do therapy.



Darkside said:


> For awhile many psychiatrists kept a practice with therapists and they collaborated. Some still do and I wish that was more common. I doubt we will ever return to a time when psychiatrists do therapy.



Probably not, for a variety of reasons but primarily because generally psychiatrists are better compensated for prescribing services than for psychotherapy services.

I don't have a formal collaboration with any physicians or psychiatrists. However, when it will benefit my client, I initiate communication. Sometimes, that is rebuffed but more frequently I find that it is welcomed by the physician.


----------



## gardens (Nov 30, 2012)

> I don't have a formal collaboration with any physicians or psychiatrists. However, when it will benefit my client, I initiate communication. Sometimes, that is rebuffed but more frequently I find that it is welcomed by the physician.



Why would a physician not welcome this kind of collaboration?  I'm kind of counting on my psychologist and pdoc comparing notes - I want an accurate diagnosis and treatment.  Wouldn't the two working together benefit the patient?  What am I missing?


----------



## David Baxter PhD (Nov 30, 2012)

What are you missing? Nothing. 

Of course it would benefit the patient. 

But some physicians, or more commonly psychiatrists in my experience, seem to have fragile egos or insecurity issues or maybe are just threatened by another mental health practitioner offering a suggestion, and they react to the perceived threats to their own egos by rejecting the input or even reacting in an oppositional manner: "Well, if he said Prozac, I'll show him and prescribe Effexor. That will show him who's the authority here."


----------

