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.
Clinical depression is a bitch. I find this film helpful, it kind of puts things more into perspective:
very big problem…
isn’t it hard to tell what is healthy
no time to talk…
we want a quick fix…
there is a pill for everything…
we are into FAST MOODS
The black market trade in cocaine is the drug people are mostly turning to, in ever-increasing numbers, as a fast fix involving a fast mood change. Typically within 10-15 minutes of insufflation the mood has markedly changed.
SSRIs can’t compete with cocaine. Whether it’s speed of mood fix, lack of side effects, deaths, or attempted withdrawal drama. Cocaine is the outright winner in all categories.
If there was a pill for everything there would be no war, no divorce lawyers, and most tantalisingly, no Love Island.
I would like a new drug that if I took it on a regular basis it would mimic the person I would now be had I never taken psychiatric drugs.
Drugs can transform mediocre artists into exceptional artists.
Antipsychotics can transform exceptional artists into mundane quit-artists. I respect their nihilistic power as I respect thermonuclear weapons.
‘expectable responses to distressing life events that signal a need for rethinking one’s life and recalibrating one’s self-perceptions and emotions’.
just like baking a cake?
what harms are associated with individual therapy ?
does it pacify people?
does it redirect legitimate anger?
does it mystify and obfuscate the causes of distress?
does it have time to explore the ‘unintended consequences of political, economical, class, ideological, media policies?
does is pathologise the individual?
do some ‘therapies’ actually encourage the person to seek out prescription drugs
does it help normalize, and reduce the irreducible and therefore help them and us to accept the unacceptable
does it often involve a therapist suffering just like most everyone else does but having to paste the face on just like a clients narrative tells of their own exhaustion with their own social facade
does it conspire with the government to get people off benefits and back to a job that will slowly or quickly harm them in many ways
psycho-compulsion anyone? harm or help? explain
does it reduce human distress down to a set of pointless scores on self assessment measures?
luckily for us as long as you score below clinical it matters not that you’re life experience with cultural disorder is crushing you, apparently you’re in recovery. you’re welcome.
Thank you, Dr. Gnaulati, for a very good description of the differences in depression. Depression certainly is not a pleasant experience to go through and hard to be around sometimes those experiencing it. However, most depression goes in time with an environment of care, understanding and self-reflection. It is quite a learning and growing experience if one can see it as that. I have been there and it does hurt but the pain can also be a source of greater focus and clarity of values, self-acceptance and needs.
I am very concerned about more MDs diagnosing this. I see this diagnosis on medical records all the time. It concerns me that patients do not even know that the Attending MD or PCP put it in their records which I see as very unethical. There are ramifications including denial of life insurance as well as providers viewing the patient differently. If this is on a medical record, we are required then to ask PASRR questions if going to a short-term rehabilitation facility. Invasive questions like “Have you been psychiatrically hospitalized in the past 2 years, does the patient exhibit evidence of a mental illness, etc.”. I find it discriminatory. And I find MDs whom I work with in family medicine, especially fairly new ones just assuming depression without getting to understand the context of the patient’s life.
I liked how the posting discussed loss in many ways, not just the death of a loved one. I see many people in my private practice who have experienced loss of a meaningful job, loss of time due to demanding work environments leading to burnout, marriage issues and children lost in the midst of their parents’ struggles. In a medical hospital, there is loss of physical ability, new diagnosis of serious medical illnesses such as cancer, being on disability and loss of social and economic status related to this. Loss is very personal and how one experience it is different and has no set formula. Stages of grief by Kubler-Ross certainly have much validity for most: anger, bargaining, denial and acceptance, depression are not linear stages.
I have a dear friend now who is going through a lot with his mother dying and has depression signs. It can be tough at times to support him as he can get irritable and lashes out at me at times so I try to just take care of myself, understand my limits of time and energy. I take walks with him and talk to him when I can. I bring food and flowers over and do my best to be understanding. “This too shall pass” is one of my mantras.
I’m going to send this article to my dad. He has clinical depression. Over the years I witnessed how serious it is.
He and I are the individuals in immediate family that have mental health challenges painful enough to involve hospitalization and decades of hardship.
The author states that: “It is imperative to distinguish between actual clinical depression, and “healthy depression…”
Yet there is no even marginally objective means offered to do so. Any of the “healthy depression” causal factors could eventually plunge a person into an extremely depressed state that seems unescapable. How about living in a domestic abuse relationship that you are unable to find the resources to escape? Living in a society where every day you are judged harshly because your skin is brown or you don’t speak the common language? What about realizing that you are trapped in a dead-end job that brings no satisfaction but can’t be stopped without risking homelessness and starvation for your family? I could go on…
The author also fails to note that most of the people meeting his vague “clinical depression” criteria have experienced childhood abuse and/or neglect, often in very extreme ways. I have known many childhood sex abuse victims who suffer from “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.” Does this merit a “medical diagnosis?” On what basis? Is this not just a more extreme version of a call for “the emotional impetus to revamp one’s life commitments in line with new, emerging beliefs and values?”
I absolutely appreciate the focus on normalizing depression. I just don’t think you’ve gone quite far enough. The concept of “clinical depression” is seductive, but separating “clinical depression” from “normal depression” is simply not a scientifically viable process. There MAY be some people who DO have a medical problem that causes them to feel depressed, but it is not possible to make that distinction based on how bad someone feels or whether or not they have sleep issues.
Thanks for the article – lots of great stuff in there for the medical profession to chew on!
Thanks Steve and Oldhead
Both responses (serious and humorous) are necessary critical responses to this blog. While the author has good intentions in his criticisms about the “over” diagnosis and drugging of depression, this still leaves the door open for harmful psychiatric labeling and drugging of those determined to be “clinically” depressed.
There is NO way to determine this imaginary “line” between “healthy” depression and “clinical” depression.
And doesn’t this second designation sound rather “clinical’ to everyone here.
Depression is a necessary and healthy evolutionary response to human conflict with the environment and various social injustices that surround us. It is an important coping mechanism that can unfortunately get stuck in the “on” position for some people in certain circumstances. And yes, this can be terribly painful and debilitating and should NOT be minimized.
BUT many people have (and will continue to ) find their way out of this morass with the right combination of social supports and time healing personal insights that emerge through difficult struggle.
Let’s NOT leave the door open for psychiatry and their oppressive Disease/Drug Based paradigm of so-called “treatment” to somehow determine what is a so-called “unhealthy” level of depression that we all need to pathologize with a “clinical” designation.
Here, in this discussion we once again have a clear distinction between what is “critical psychiatry” and what is genuine “anti-psychiatry.” And it should be obvious from my comment that I stand firmly with the latter.
“Let’s NOT leave the door open for psychiatry and their oppressive Disease/Drug Based paradigm of so-called “treatment” to somehow determine what is a so-called “unhealthy” level of depression that we all need to pathologize with a “clinical” designation”. Great quote there, Richard. Let’s create a kinder, more loving and nurturing environment in ourselves and those in our immediate circle and outside of it, that is my cure for depression. Psychiatry and now GPs and NPs have done nothing for depression except feed its own self-interest and poison our bodies. Some people do not have supportive friends or family and the way out is making changes to that environment. I do not see anything wrong with seeing a therapist for a short-time if that helps. Priests, rabbis and ministers also can be helpful. But the goal of counseling or therapy should be connecting people with healthy supports in the community not having the individual overly dependent on a professional for support.
I also don’t find value in distinguishing “healthy depression” from “clinical depression.” “Clinical depression” too often just means a depression that the clinician is unable to, or too lazy to, understand the cause for!
But I do think depression is kind of like fear: sometimes it is really helping us, and other times it is more based on misunderstanding, exaggeration, etc. So I might be depressed about my relationship or job or even my whole way of being in the world, and that might be helpful and realistic, because there might be something terribly wrong with my relationship or job or way of being in the world, and I need to slow down and face that and let it sink in so maybe I can find some other path. Or maybe I feel everything is depressing, but it really is just an irrationally dark view, and what I need to do is to question my dark thoughts and see the value of jumping back into life without making any big changes.
A key thing here is that it shouldn’t be clinicians deciding which is which: people have to make these decisions for themselves, though clinicians can collaborate with them in doing that, or facilitate thoughtfulness about it. It helps to have a clinician who isn’t too sure that the only thing needed in each case is rosier colored glasses to look at the world through……
I understand and agree that ideally clinicians should not be making that distinction and it should be the person that defines what they are experiencing. I am finding myself though having clients wanting FMLA, disability or school documentation completed by me and/or a MD stating that they cannot work or go to school due to depression. Of course the paperwork wants DSM-V clinical language to support it. Professionals are being forced into this by the client at times.
Good point, Steve and Richard!
The difference between “clinical” versus “healthy” depression?
One is diagnosed by a doctor. The other you keep quiet about.
Very good! Or here’s my try: “Clinical depression” is the one we can make money off of.
Here is another.
“Clinical Depression” is the kind you get when the “mental health” system labels your deep emotional angst as “clinical” and then drugs you to boot!
Sounds pretty depressing to me!
I refer to this point precisely sir when talking with individuals and families. The two seem markedly different. You included many valid points in your rundown.
In addition ya all I made quite a few attempts to reference this to everybody on here in comments over last year.
Maybe this will help:
Understanding depression and its causes
Depressive disorders often co-occur with anxiety or substance abuse and are a leading form of disability in the United States. Depression may strike any time without warning. Researchers have identified the five primary causes of mild, moderate and severe clinical depression:
1. Imbalance of key chemical neurotransmitters in the brain;
2. Chronic low-grade hopelessness generated by early childhood trauma;
3. Marriage to the wrong person;
4. Sudden realization of the essential absurdity of life;
5. Ecological catastrophe on a scale never before seen in human history.
Other factors which might trigger a depressive episode include:
* having either too much or not enough of something;
* being trapped in an utterly hopeless situation with no way of escape;
* remorse, guilt, shame, failure, disappointment, frustration, grief, heartache, pain or loss of some kind;
* infestation of household pests such as termites or rodents;
* omega-3 deficiency from not eating sufficient quantities of cauliflower and other vegetables;
* leaky faucet, clogged drain or similar plumbing problem;
* global economic collapse, thermonuclear war, mass starvation, genocide, etc.
from “Asymptomatic Depression: Hidden Epidemic and Huge Untapped Market” http://www.bonkersinstitute.org/asymptomatic.html
Thanks, Oldhead, very good serious and funny points. Bad hair day is always a bummer too for me. Thanks, for levity, sense of humor is always good to have.
If you liked the excerpt check out the link and the whole Bonkers Institute site, it’s an underappreciated gem.
Thanks, oldhead. I checked it out, hysterical but scary too as probably not too far off from how psychiatry did market itself. Ethics, smethics…
I was thinking along these lines too Oldhead. My term here was cumulative depression, in the more pernicious cases, beginning in early childhood ( your#2) before a child has suitable developmental consciousness to differentiate their (external) trauma from ego self, etc. If childhood trauma is ongoing (developmental trauma) the likelihood of your other factors is exponentially likely, save compounded. Suffice to say…the discussion (long, hard, and honest!) for the safe space and treatment of healthy depression is overdue.
Actually that wasn’t me but a quote from a primarily humorous article with just enough grains of truth to sound credible on the surface. However #1 & #2 do represent the two basic takes on “depression” these days.
We need to defend psyche from apollonian theologic state of terrorists, like The Black Panther their people. Yes. When sb is happy, no one talks about him in medical/clinical way, and when sb is sad, there must be clinical cause, this is insane. This is completely rejection of psychological meaning of not being happy for just not being happy (and this is theology), because we can’t all be psychologically stupid enough to be happy. And there is a Hades reality to which belongs also the least psychological apollonian—– HAPPY ALL THE TIME—— archetype. AND HE IS NOT THE ONE WITH ABILITY TO JUDGE. NO ONE IS, because Hades is the ruler of psychological reality and apollonian must obey to the rules of hades. Because that is the psyhcological truth. Apollo is not the father of the psychological world, it was Zues and Hades. Apollo is too shallow and to blind to recognize the deep psychology, that is why people in HADES are invisible and rejected.
People happy are NOT REAL in psychological meaning, they are living out of touch with reality of death, there are not psychological, they are EGOIC . AND THE DEATH IS THE ONLY TRUTH IN PSYCHOLOGICAL LIFE. Mentaly healthy means – psychologically blind to death/psychological reality WHICH IS the truth REALITY.
And the problem with the easy apollonian archetype is that they won’t admit it THAT THEY ARE UNREAL (BECAUSE WE ARE HEALTHY), because PSYCHOLOGICAL MAN IN RENEASSANCE MEANING SHOULD BE THE ONE WHO IS WORSE.
I am sorry, but theology and rulers of shallow materialistic (ANTIPSYCHOLOGICAL) world means nothing for the law of psyche, for death.
LIKE I SAY PSYCHE NEED THE THE PROPER LANGUAGE, THE TEMPLE NOT THE HOSPITALS FOR VICTIMS. WE NEED PHENOMENOLGY OF PSYCHE IN THE PLACE OF DSM AND BIOLOGICAL PSYCHE FALLACY. AND THE RESSURECTION OF PSYCHOLOGICAL MAN.
JAMES HILLMAN RE -VISIONING PSYCHOLOGY.
I have a mental illness…
I am unipolar….
There is a humour to be found in depression. I’m making it sound simple. Perhaps because it is simple. All you have to do is allow your inner joker to breathe, and before you know it, little beads of joy will fall upon you.
I remember only once being reduced almost to tears in one conversation with one particular psychiatrist. He was on the brink of joy too. I am sure of it. We were talking about bipolar and magnets. Attract and repel.
It is true that in the manic phase people are drawn to me when I’m out and about. A phrase I often hear is: “I’ve never told anyone about all this before.”
When people feel safe, they open up. I think beforehand they’ve picked up on the energy and it’s enraptured them in some way.
It is a wonderful thing.
It feels good to buzz off people. People start to wake up when they laugh a lot. A levity washes through them. A sparkle returns to their eyes.
For every person there is a funny thought or an amusing story or an absurd circumstance that can break the magic spell of their unbudgeable downer.
Everyone has the capacity for joy and laughter.
I feel negative emotions pretty strongly. But this can be a good thing.
Because I feel guilt I am less inclined to do what is wrong and will fix wrong stuff I have done.
Because I feel sorrow I can empathize with others in pain. Remember the character Sadness in Inside Out? Joy realizes Sadness is just as necessary as she is.
Unhappiness can be a great tool in prompting necessary life changes.
Take a woman in an emotionally abusive relationship. She feels depressed. She needs to realize why she is depressed and leave the guy.
What she does not need is being told she’s crazy and a bunch of drugs to numb her so she’ll let the abuse continue. Abuse victims blame themselves too readily to begin with. The last thing she needs is a psych label since her boyfriend will probably use it for gas lighting and other creepy stuff.
An excellent point! Diagnoses are used all the time to further abuse of women, and particularly to get custody of kids away from a protective mom.
I had been following a couple forums for people who had been spiritually abused.
(Both my brother and I were pretty frightened by a Sunday school teacher telling us we had to be good to avoid Hell. Being good meant not asking hard questions in Sunday school, crying, or ever disobeying a grown up. A bunch of other crap happened–as a preacher’s family we were frequently on the point of homelessness. Common in the Church of Christ.)
I got angry and left one forum when they were counseling battered wives to seek professional “help” for depression. Ugh. They meant well…but how could anyone be that stupid? Obviously they watched a couple SSRI commercials and think they know everything now.
Thank you to the author and all of us who understand the different forms of depression. I am an RN, working within Hospice, or rather the death industry. The chronic use of anti depressants at end of life is sickening. The work we do at this time of our life is vitally important. Again, thank you.
I managed to cure my clinical depression by leaving the Mental Illness Factory known as psychiatric treatment.
No longer depressed or pessimistic. After more than 15 years grappling with suicidal desires.
Finally hopeful and I feel happy sometimes. I owe it all to disobeying “doctors'” orders. 😀