A recent Blue Cross Blue Shield report documented a 33% spike in diagnoses of depression in the United States from 2013 through 2016. It was concluded that depression ranks just below high blood pressure as the condition of greatest importance adversely impacting overall health.
It’s tempting to attribute the upsurge in diagnoses of depression to the push for primary care physicians to screen for depression. Non-psychiatrist physicians are not only becoming de-facto depression screeners, but front-line mental health practitioners. It is estimated that close to 80% of antidepressants are prescribed by non-psychiatrist physicians.
As more and more physicians see the treatment of depression as falling under their purview, in combination with the new emphasis on integrating medical and behavioral health care, it is likely that the upwards trend in depression diagnoses will persist. It will persist because the more depression is assessed for and treated through a medical lens, the greater likelihood that normal and healthy states of depression will be pathologized and lumped together with actual clinical depression.
It is imperative to distinguish between actual clinical depression, and “healthy depression,” or the adaptive and expectable responses to distressing life events that signal a need for rethinking one’s life and recalibrating one’s self-perceptions and emotions.
In clinical depression there is ingrained pessimistic thinking; disturbances in sleep and appetite; lethargy; difficulties concentrating; pathological guilt over real and imagined transgressions; isolation; dire hopelessness; and, a despondent mood. The clinically depressed person may be haunted by suicidal ideas. Ending one’s life may seem to be the only solution to rid oneself of the psychic pain, sense of despair and futility, and hateful self-images that are believed to be permanent features of life.
In healthy depression, there’s less a sense that one’s overall sense of self is deficient or defective, but that the person we imagined ourself to be, and valued so highly, is now less imaginable. There’s a diminishment of self, rather than a fragility of self. The onset of depression signals us that we somehow need to square our self-beliefs with our actual attributes, talents, and achievements. Emotional well-being requires that we form estimates of our attributes, talents, and achievements which are accurate and stable. If we walk through life underestimating or overestimating who we are, we potentially set ourselves up for perpetual distress. Transitory depression can signal us that it is folly to keep seeking out more attractive mates than is realistic, for example, or to pursue career positions that are out of our league, or fail to accept functional limitations brought on by chronic illness. We may hold out emotionally and be angry and irritable: Why can’t we have it all? Life is unfair! But sooner or later, irritability and anger needs to be supplanted by the grief-laden, loving acceptance of who we really have become, and that’s okay.
Typically, healthy depression is characterized by identifiable losses and accessible sadness. It may be the loss of a romantic relationship, a valued employment position, or athletic ability due to illness. If normal sadness is confused with clinical depression and medicated, opportunities to grieve the loss, emotionally process it and learn about oneself, possibly in psychotherapy, are foreclosed.
For clinically depressed people, isolation often serves the purpose of escaping from a life that is unbearable and perceived to forever be that way. The person has little energy to be social in basic ways—to smile when smiled at, or to wave back when waved to. Attention and concentration are impaired. That’s because the person is so preoccupied with his or her own faults and feelings that he or she has little mental energy in reserve to concentrate on other things.
However, a need to isolate oneself can be a healthy aspiration in someone experiencing transitory depression. Attention paid to others and outside commitments can take focus and energy away from the attentiveness to self that yields emotional insight only acquired with solitude. Being alone helps us zero in on and shed old ideas about ourselves and our lives. It allows for introspection that brings self-perceptions of one’s personal worth and attractiveness into alignment with one’s new life circumstances. It allows us time and space to arrive at a fuller awareness of the new rules with which the game of life should be played. We might call this “productive solitude.”
When we treat guilt as a symptom of depression to be medicated, or eradicated, we lose sight of wholesome types of guilt. Guilt, along with shame, is one of the social emotions. Guilt feelings can signal us that we have harmed someone who matters, requiring remedial action, to preserve a needed bond. Relief from guilt can be obtained from acknowledging any harm caused and making amends. Another type of “good guilt” is what humanistic psychologists call “existential guilt.” This involves a nagging feeling inside that we are not living up to our potential, not bringing to fruition the gifts and talents that we posses. It’s the voice inside our head that’s telling us we’re frittering away our life, have become too complacent and set the bar too low. Heeding the call of existential guilt keeps us honest about abiding by our inner ideals and realizing our capabilities.
“Bad guilt” is pathological guilt, which is found in clinically depressed people. This involves a global feeling of badness. It’s as if the person has an overactive conscience where they’re preoccupied with having done something wrong, or being about to do something wrong. The tragic part is that, in reality, the person is decent and well-meaning.
At times, depression is really apathy. It results from a person’s having sacrificed his or her autonomy, passively living a scripted existence and unsuccessfully trying to ignore a dawning awareness that the social or religious conventions that ought to instill meaning have lost all relevance. The dysphoria felt around this, if heeded, is the emotional impetus to revamp one’s life commitments in line with new, emerging beliefs and values.
Likewise, depression can alert us that we are stuck, neglecting to act on know sources of personal enjoyment and fulfillment that can no longer be denied; or, depression can be the upshot of remaining in stagnating relationships with the stagnating effects finally being felt.
Disclosures of suicidal ideation should not always be approached with alarm and protective action. For some people, confessing suicidal thoughts is tantamount to communicating that the life they are living has become unlivable, and needs to be re-thought and re-approached. There may be more hope than hopelessness, because the despair one feels gets processed as a call to action, a painful reminder that some essential life changes urgently have to be made.
Now, more than ever, with the increasing medicalization of depression, we need to separate out healthy depression as a relatively normal human response to loss; an innate signaling system harkening us to thoughtfully and emotionally recalibrate who we are, who we have become, and who we need to be; and an indication that productive solitude might be needed for a period of personal introspection, and that sadness, guilt, and remorse, if acknowledged and processed, will provide relief and acceptance.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.