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Jul 05 2014

Depression Is Not Sadness (Again)

[Content note: mental illness, depression, anxiety, suicide]

When I think about the frequent charge that therapists and psychiatrists and those who work with them are trying to “medicalize” “normal” emotions like sadness and fear, I think that people don’t really understand how emotions like sadness and fear can be distinguished from mental illnesses like depression and anxiety.

I’ve tried to explain this to many people multiple times, in person and through writing, and so have many other people with mental illnesses as well as professionals in the field. Yet people continue to conflate emotions and illnesses, or rather to assume that mental healthcare advocates are conflating them. It’s often difficult to continue engaging patiently with this claim.

Even those who are knowledgeable about illness and disability make this error. In an otherwise-fantastic blog post about the medical model of disabilityValéria M. Souza uncritically cites this very inaccurate view of antidepressants:

In The End of Normal: Identity in a Biocultural Era, Lennard Davis affirms: “A drug would be a prosthesis if it restored or imitated some primary state that appears to be natural and useful” (64). Davis makes this statement in the context of his argument that SSRIs are not “chemical prostheses” for depression, since happiness is not a “primary state” of being and since there is compelling evidence to suggest that SSRIs do not actually work (Davis 55-60).

I’ll address the SSRIs-not-working thing first since I have less to say about that and it’s not as relevant to this post. The reality seems to be more that SSRIs work well for some people but not at all for many other people and we haven’t really figured out why they work for some people but not others, or more specifically, which types of people they work for and which they don’t. And on a personal note, I’m a little tired of being told that SSRIs “don’t work” when they’re part of the reason I didn’t try to off myself four years ago. There is compelling evidence to suggest they do not actually work and there is compelling evidence to suggest that they do actually work, so I’m comfortable saying that the jury’s still out on this one.

More to the point: antidepressants are not meant to cause “happiness” because depression, the illness they are meant to treat, is not defined by a lack of “happiness.” Depression involves a constellation of physical, emotional, and behavioral symptoms that make happiness very difficult or even impossible. These symptoms have a number of other deleterious effects which vary for different people. There are many ways depression can ultimately “look,” such as being unable to get out of bed, being unable to hold down a job, bursting into tears several times a day over tiny inconveniences or in response to nothing at all, losing your sex drive, being unable to sleep, having to sleep over 12 hours a day, having severe memory loss, losing the ability to enjoy any previously enjoyable activity, experiencing complete emotional numbness, obsessing over death and suicide, physically hurting yourself, or attempting suicide.

Maybe being “happy,” whatever that even means, isn’t a “primary state,” but I would argue that being able to live a relatively normal life in which you can go to school or have a job, have relationships with people, and not want to kill yourself is a “primary state.”

Being treated for (and, hopefully, recovering from) depression does not give you extra things that other people don’t have, such as constant happiness and optimism. It gives you what everyone else has had all along, which is a reasonable and age-appropriate amount of control over your emotional state and the ability to create your own happiness if you want to and make the effort.

By the way, you can definitely be miserable and unhappy without having a diagnosable mental illness, but it’s rare to find a person whose unhappiness is truly caused entirely by their own voluntary actions. Depression can also develop as a result of voluntary actions; for instance, if you have a number of career options available to you but you choose an extremely stressful and mind-numbing (but perhaps lucrative?) option, you might end up becoming depressed because of it. At that point, your best bet might be to find a way to make a career change, but it’s likely that you’ll also need therapy to help undo the maladaptive mental habits that the situation has created. (Medication might help too, but in a case like this I’d personally recommend therapy first.)

I think a better way to explain the difference has been that, at least in my experience of mental illness versus mental health, there are things that mentally healthy people can do to significantly increase their level of happiness, whereas people who are going through a bout of mental illness can rarely make a huge difference just by stopping and smelling the roses or making more time to play with their kids or enrolling in a cooking class or whatever. They can maybe make a small difference, but it’s unlikely to reduce the mental illness symptoms themselves. I used to get so frustrated at things like The Happiness Project and other initiatives of that sort, until I finally realized that they weren’t aimed at me because happiness would literally not even be a possibility for me until I treated my damn mental illness.

(That said, things like that can be very useful for someone whose mental illness is in remission or otherwise low-grade. Right now, I’m not fully symptomatic for depression but I’m aware that it can probably come back at any time, so I do a lot of things to keep my mental health strong to try to avoid it coming back.)

It’s difficult to tease out all the complicated interactions between mental illness, mental health, and happiness, and of course it varies for different people. In my experience–which includes my personal experience, my interactions with friends and partners, and my studies and clinical experience, here it is in a nutshell: untreated/unmanaged mental illness makes happiness virtually impossible to achieve. Treating or managing your mental illness, whether through medication, talk therapy, or personal lifehacking, helps make happiness possible to achieve. But the work of achieving it is still yours to do. No drug or therapist can just give you happiness.

And most people with mental illnesses realize this. I haven’t met anyone who was just like “I wanna go to the psychiatrist and get a pill and just be happy always forever.” Most of us just want to stop crying all the time, or stop having panic attacks whenever we need to interact with new people, or stop having intrusive and scary thoughts of killing ourselves, or stop lying awake for hours each night because we can’t stop imagining all the bad things that could happen to us.

“Happiness” is the cherry on the sundae of mental health. You need to put the ice cream and the syrup and the whipped cream in the cup first.

(I’m not sure what it says about me that in reality I actually despise maraschino cherries and always ask for them to be left off my sundae. This is an analogy that was definitely intended for the presumably more normal people who will read this.)

If you still think that what we call “depression” is just an attempt to medicalize “sadness,” then you don’t know what one or either of those things are. So I’ll illustrate with an example of an internal monologue I have had when I was sad, and one I have had when I was depressed. The subject is the same, but the emotional response isn’t. See if you can figure out which is which!

I really wish I had a partner. It’s lonely not having anyone to come home to and it feels crappy seeing all my friends with their partners even though I know I should be happy for them. Sometimes I wonder if I’m just not that attractive or likable as a person. It seems like I’m the only person not dating anyone. I hope I meet someone soon, but I don’t know when or how that will happen and I’m not that optimistic about it right now. 

I really wish I had a partner. I feel like a complete worthless failure because literally everyone else I know is seeing someone and I’m not. I’ll probably never find anyone and I’ll just be lonely for the rest of my life and there won’t be anyone to call 911 if something happens to me and they’ll find my body in my apartment days later because nobody gave enough of a fuck to check on me. Not like I blame them. I’m so ugly and stupid that I don’t know why anyone would even want to hang out with me, let alone go out with me. Everyone’s probably pitying me because I don’t have anyone and everyone can tell that it’s because I’m completely pathetic. I feel like I might as well not even exist because what’s the point of going through life alone and unloved?

One of those is a sensical reaction to lacking something in your life that’s important to you (a romantic relationship); the other is over-the-top. The emotional response in the second example is disproportionate; it doesn’t make sense to leap all the way from “I’m sad because I wish I had a partner” to “I’m a worthless failure and will die alone.”

That second monologue contains a number of characteristic cognitive distortions associated with depression, such as all-or-nothing thinking (I have to have a partner or there’s no point in even living), disqualifying the positive (the good aspects of my life are irrelevant; it’s all bad because I’m single), mind-reading (everyone must be pitying me), fortune telling (because I don’t have a partner now, I will never have one), catastrophizing (something bad will happen to me and I’ll die alone in my home because nobody will help), personalization (it’s completely my fault that I don’t have a partner; none of it comes down to chance or being in the wrong environment or anything else), and emotional reasoning (I feel like a failure because I’m single; therefore I definitely am a failure).

While mentally healthy people do make cognitive distortions too, mental health is a spectrum: the more you’re able to refrain from thinking in these harmful ways, the more mentally healthy you’ll (generally) be. If you look at the first monologue, you’ll see some slight distortions, like the fear that you’re unlikeable or unattractive just because you happen to be single, or the perception that you’re the only person not dating when that’s obviously not true. But only in the second example do these irrational thoughts become all-encompassing. And, importantly, only the second example involves thoughts of death and suicidal ideation.

Note also that in the first example, being single is causing sad feelings, whereas in the second example, the emotional responses are not primarily caused by the singleness. Perhaps being single is the immediate trigger of the extreme sadness and negativity, but what’s really causing it is depression. A depressed person who is miserable about being single will not stop being miserable if they stop being single; they will usually be miserable about other things. That’s exactly what happened to me back when I was having that monologue. I’d inevitably get into a relationship and then be miserable because I didn’t think my partner liked me enough, or because I was worried about school, or because I felt like all my friends hated me, or because I hated myself, or just because.

Depression can trick you into thinking that you’re depressed “about” something. You’re probably not. You’re depressed because you have depression, and luckily, you can treat it.

Sadness, on the other hand, is about things. You can be sad because you’re single or because you got a bad grade or because you hate your job. Sadness is a normal, healthy reaction to experiencing things that you don’t like. It’s a useful and important emotion because it tips us off to situations that we should try to change if we can. Sadness can prompt us to take a step back and think about things and how we would like them to be better.

Medicalizing sadness and medicating it away would probably harm individuals and also our society as a whole. It would make things pretty boring. Isn’t it great that antidepressants and therapy are not actually trying to do that? Isn’t it great that we can help people avoid catastrophic, paralyzing, life-ruining sadness and fear like the ones associated with mental illnesses, while helping them get in touch with healthy and situationally appropriate sadness and fear? That we can help them understand their emotions and use them to change themselves, their lives, or the world, without having their lives completely governed by them?

Indeed. Depression is not sadness. Anxiety is not fear. Nobody is actually trying to eradicate sadness and fear.

~~~

At Skepchick, Olivia has a great take on this, concluding that:

I do think that it’s important to address our societal phobia of sadness, grief, and pain. But the way to do that is not to throw the mentally ill under the bus by implying they are running from their negative emotions when they seek out treatment. It also doesn’t mean casting shade on the few tools for treatment of mental illness that we actually have evidence are effective. A diagnosis of depression does not say “this person is too sad”. It says “this person can’t function the way they would like to because their emotions are consistently out of control”. There is a world of difference between those two statements.

24 comments

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  1. 1
    Andrew B.

    Slightly off topic question: Have you ever felt uncomfortable with optimism? Like, you’ve had so much failure that now that something good seems to be happening, you’re just waiting for the other shoe to drop? Is this a result of having become so “guarded” as a result of your hopes being consistently dashed that your subconscious is telling you “don’t get too comfortable with these nice feelings, because you’ll be that much more devastated when things inevitably turn to shit?”

    1. 1.1
      Miri, Professional Fun-Ruiner

      I don’t relate to that personally, though I’m sure plenty of other people do.

      Let’s try to keep the discussion more-or-less on topic, as I think there’s a lot to talk about here.

  2. 2
    badgersdaughter

    Miri, thank you for posting this. My husband is from a country where there are few therapists and the ones that exist are largely for the most ill. He never did understand why I needed a therapist while we were waiting for his green card, calling it an “American luxury”. At the same time he doesn’t really process what it is to have been seriously depressed and anxious through the grueling wait for the green card to process. This article, pointing out that I wasn’t just frustrated and sad, but “crying nonstop for no reason”, “panic attack at the grocery store”, “forgets to take showers”, “can’t see a way out” ill, will help so much.

  3. 3
    Valéria M. Souza

    Hello,

    Thank you for your thoughtful post.

    To be honest, I had (and continue to have) a complicated relationship with Lennard Davis’ chapter on depression, and I am not completely sure that I agree with his views on depression and SSRIs. With that particular quotation, I was admittedly more focused on “outside-of-the-box” concepts of prostheses—-namely, whether an immuno-modulatory drug can properly be considered a kind of prosthesis. Davis’ chapter is the only recent work in Disability Studies to broach the question of “chemical prostheses,” and hence I cited it. Have you read the chapter in its entirety? I would be curious as to your thoughts on it. (My post omits much of the context of Davis’ argument, since covering that ground would have lead me too far outside the bounds of my own post topic.)

    Thank you again.

    Best,
    Valéria

  4. 4
    Bruce

    Hi Miri,
    Please give me your pros and cons on to what extent the following could become a useful analogy, even though I know it is not fully valid.

    In some ways, depression relates to sadness emotions as osteoporosis relates to bone fractures.

    That is, depression and osteoporosis are about the likelihood or ease of having a bad event happen, while sadness or a bone fracture are bad events experienced from a variety of different causes and factors.

    Thus, a patient with osteoporosis that goes to a good doctor should not be told to go away because they don’t currently have a detectable fracture. The patient should not be told that their goal is a pill that will let them pick up a car because of that pill giving them unbreakable bones (like unbreakable happiness). Instead, the patient should be checked for a calcium deficiency and other factors that might make some future fracture more likely. The patient should not be told that they are weak and need to spend more time on the weights machine with no guidance. Instead, the patient needs proper diagnosis and treatment, and also counseling and coping strategies, and perhaps a bit of time doing extremely light exercise but only under close professional guidance until things are stabilized and responding.

    Most of all, a patient with osteoporosis ideally is never told that it is their imagination and they can just walk it off. Every doctor in the western world knows that even if they can’t diagnose osteoporosis by themselves, they can send a patient to a specialized clinic with instrumentation that can unambiguously and quantitatively evaluate bone density relative to normal standard deviations and give a diagnosis that fits with all observable trends.

    Unfortunately, such a perfect diagnosis for depression does not yet exist, but there are still many useful things that can be done if one meets with a doctor who is open to the possibility that this may be the situation.

    So can we think of ways to fine-tune this analogy to help others understand the issues here? I am no professional, but it seemed to me that this idea might be useful for some to explore. Thanks.

  5. 5
    Jadehawk

    I have no problem sorting out temporary and moderate sadness from my depression; what I do have a hard time with is this:
    when I’m feeling like shit because I feel like I’m never going to be not poor and I’m never going to be able to finish school and have an academic career… I don’t know whether that’s being depressed or being permanently sad over a permanent shitty reality; because there really are no jobs, there are certainly no well-paying jobs in the areas I’d be interested in, and every attempt at moving forward with my education is actually being blocked in ways that are absurdly hard to overcome, depressed or not.
    Basically, assuming there existed a drug that could fix my depression, would anything about that particular situation change? I don’t know. I can’t tell. And I mistrust anyone who tells me that this pessimism about my future is just my depression, because prospects for millennials really ARE shitty, and there really IS a devaluing of academic work so that doesn’t really pay well anymore, and I really DO face ridiculous barriers to finishing school. But if I’m not able to trust a therapist to help sort out which are genuine fears and which are disproportional on this issue, how can I trust them on others?

    What I’m sort of trying to say is… how does one sort out when not functioning in society and being pissed/in a low mood permanently is a social condition, and when it’s a psychological condition?

  6. 6
    opposablethumbs

    I also wonder the same as Jadehawke.

  7. 7
    AMM

    Re: anti-depressants.

    I’ve used SSRIs (Paxil, later Serzone), and am now on Wellbutrin. My experience with anti-depressants is that they don’t make the depression go away, they just make me not care as much about all the depression stuff, so I can go ahead and do what needs to be done anyway. Which includes trying to find some way to make my life (outer and inner) less depressing. (Maybe someday I’ll be able to make myself clean the bathroom….)

    Oh, in case it wasn’t obvious: YMMV.

    tl;dr: they are _not_ “happiness in pill form”; I wish they were!

    1. 7.1
      HFM

      That’s been my experience as well. The meds don’t fix the cognitive distortions, but they do give a feeling of distance from them – instead of being provoked into an emotional response, you have the space to evaluate the thought calmly and redirect into something more rational and constructive. I think of the meds as “training wheels” for the (hard!) work of learning good mental hygiene. (I’m not “blue” at baseline, though – just mildly OCD, which can fester into depression if I’m not careful. YMMV.)

  8. 8
    jesse

    Miri– I would submit that part of the problem is psychology itself (as a discipline) hasn’t exactly covered itself in glory, and that rather too often psychology has been used as a weapon against anyone who doesn’t conform.

    That doesn’t invalidate your issue with the difference between mental illness (depression in this case) and sadness. The point is that when psychologists screw up enough times, there’s a lot of “splash damage” on psychiatrists. The old parody of the talk therapist is relevant here. (In the 70s the old joke from Woody Allen in Sleeper was common — “It’s been 200 years, if I’d kept seeing my therapist I’d have been cured by now.”)

    Let’s not forget that homosexuality was considered a mental illness until recently, too, you know? So people conflate that kind of thing. Yes I know, that isn’t the way it really is, but there’s a lot of things that aren’t really true that get popular currency. Yes, the stuff I am talking about is old, but that’s sot of the point, ask most people what a psychologist does and they still have an image of Freud from 1920 or a therapist ca. 1975.

    Anyhow, point is, when people talk about medicalizing sadness, they often are referencing something very real (and worrisome) which is treating any deviation from a perceived norm as an illness.

    One example is ADD/ ADHD. I have yet to see a quantitative description of what those are supposed to look like. Is there an average number of seconds a child should be able to stay on-task, for instance? Is there an average memory retention time we should expect from a person at developmental stage X? If there’s a paper that says what those are supposed to be I haven’t sen it (and please, please tell me if it exists and I just ever heard of it it isn’t like I am an expert).

    So parents take their kids in, insurance won’t cover any therapies that take more than a couple of sessions to do, and so drug become the go-to. Yet the problem might just be a kid who is slightly towards one end of the curve. So it looks like clinicians are just making this stuff up. I know they aren’t, and you know it, but that isn’t what it looks like.

    And then look at who gets diagnosed with behavioral problems. I don’t think I need to tell you who.

    So psychology and psychiatry have a pretty ugly history sometimes, and I think now we’re paying for that with the kind of attitude you are describing. And this is a little different from other medical sciences: there are lot of people old enough (myself included) to remember what measles and whooping cough look like, and to have had mumps, and my parents can remember polio. So even with all the ant-vaxx silliness, that’s something where the effects and effectiveness are so obvious that there’s a reason anti-vaxx stuff is more rife among people under 50 (note that all the young parents on the bandwagon are just that- most will be under-40s). Yes, other medical sciences have had serious ethical lapses — hello Tuskeegee — but in many other areas that directly touch people’s lives there are and were real, concrete results that you just can’t argue with, and these had time to percolate into the popular imagination (there’s a whole other problem here, of course, where much of the medical profession is a victim of its own success, but that’s another discussion).

    The mental health fields, on the other hand, haven’t got as much of an obvious, in-your-face record, as the illnesses are more subtle, and tied in with behavior and a zillion confounding factors. So the successes they have had are harder to see. But the failures are much easier to see — just ask anyone who was put in a mental institution for being gay.

    I mean, think of the Rosenhans experiment. If that was a one-off, that’s one thing, but it’s not. There are loads of similar experiments that seem to show at best that the average psychologist doesn’t know what they are talking about and is easily fooled. And worse, that their biases -race, sex, gender, class– will affect their diagnoses in ways that have pretty serious consequences.

    Psychiatrists do something different, but the fact is they end up in the blast zone when stuff like that explodes in people’s faces.

    That doesn’t work with cancer (you can’t really fake that) and say, a broken leg or curing bacterial illness. I can’t fake cancer and get someone to force chemo on me, you know? Or say “I have a brain tumor the size of a golf ball” and fool a neurologist. And of course the first question people will ask is that if they can’t trust a psychologist to know what’s up why should they trust a psychiatrist?

    Again, I stress that none of this makes psychology or psychiatry invalid. But it hasn’t helped the popular attitudes. And I think it goes a long way to explaining why you have to write posts like this all the time.

    1. 8.1
      Miri, Professional Fun-Ruiner

      I would be more willing to accept this as an explanation for the phenomenon I’m discussing if the bulk of these reactions were actually targeted at mental health professionals and researchers, not at the people who utilize those services. The fact that it’s mainly targeted at people experiencing mental health problems (“You just want to take a magic pill and be happy!” “You think being sad makes you special/ill!”) suggests that it’s more about ableism than about a justified mistrust.

      But also, while I wasn’t around in the days when homosexuality was in the DSM, I’m willing to bet that most queer people resisted the idea of themselves as mentally ill, just as African American slaves never thought of themselves as having an illness called “drapetomania.” Those were oppressive definitions imposed on marginalized groups without their consent.

      On the contrary, most people with actual mental illnesses are fighting to get treatment and recognition of their suffering. We want help. If I say I need treatment for a mental illness, then I need treatment for a mental illness. It’s not anyone else’s place to say that I don’t really need help; it’s just the evil psychiatrists brainwashing me or whatever. I’m suffering. I want to stop suffering.

      I’m probably preaching to the choir; I don’t think you’d actually disagree with this, but I think it needs to be said. And I don’t think I buy that charitable of an explanation for mental illness denialism.

      1. 8.1.1
        jesse

        I was trying to get across that coupled with the unwillingness to deal with mental illness generally, the stuff I was talking about doesn’t help. So I don’t really disagree with you on that point I don’t think.

        One other thing: remember, mental illness is not like a physical one. Yes, you know what it means, and I like to think that I do, but look at your speech patterns and basic assumptions about your day. We all assume that mental process are basically under our control. That is, I can decide whether I want a pizza or a PBJ and make an only semi-conscious decision not to you know, do weird sociopathic stuff like run over the old lady in the street on my bike. I can say to myself that it isn’t worth getting too upset about dropping a glass and breaking it in the sink. It’s sort of fundamental to how we experience consciousness.

        So when you talk mental illness that’s hard for people to get their heads around sometimes. We tend to see feelings and thoughts as separate from physical reality. So the very idea of mental illness as amenable to physical intervention is sort of a modern one. One reason for the denialism isn’t just that people are “ableist” but that other people simply can’t get into your head. If I see you get hit by a car I know for a solid fact that you need a hospital. When you say “I need help because I am feeling X” that’s a very different experience for everyone else because you can’t see it.

        Now add to that the very real problems psych has as a science (honestly, I’d put psychology at the same point where physical medicine was 200 years ago, groping its way to being an actual science) and you have an easy way for people to brush off mental illness. I don’t think you can deny that i the popular imagination, when you have illness definitions that basically fit everyone at some point in the day it makes it easy to dismiss, you know?

        You mention that you’d expect the ire to be directed at professionals in the field. You’re assuming that people are rational about this stuff. Most folks don’t know any professionals, nor are they hip to it the way you are. So when you get a field that has definitions of disease that are so wide-ranging that it gets positively silly sometimes (to those who aren’t in it) well, what do you expect when someone says they are mentally ill?
        If everyone is ill, with symptoms that describe what most people see as trivial — remember the bit about mental processes — why do you need a doctor?

        I know, I know, this reasoning isn’t sound. That’s the point. Most popular reasoning isn’t sound. Heck, expecting humans to use sound reasoning on any given day is a mug’s game — if people did that at all the world would be a very different place.

        What I am saying is, when discussing mental illness you’re asking people to embrace stuff that is deeply, deeply counter-intuitive. It’s like explaining quantum mechanics or national debts — neither works the way they are “supposed to.” No wonder it’s a problem.

        1. 8.1.1.1
          Miri, Professional Fun-Ruiner

          Your tone is coming across as though you think that I (a person who has had a mental illness for over a decade) don’t understand that people have a hard time understanding mental illness. In social justice jargon, you seem to be ‘splaining a little bit; jargon aside, I feel like I’m being condescended to. Believe me, I know all of this. I don’t need to be told. In fact, it’s hurtful to be given yet another reminder that most people find my experience incomprehensible and no wonder they treat me badly.

          I doubt you mean to come across this way, so I’m letting you know that so you can adjust accordingly.

        2. 8.1.1.2
          queequack

          I don’t think you can deny that i the popular imagination, when you have illness definitions that basically fit everyone at some point in the day it makes it easy to dismiss, you know?

          Yeah. Also, bluntly, it doesn’t help that so many people self-diagnose themselves with “depression” because they’re moody or unhappy and by Christ they need to itemize every last feeling they have and hey, depression means you’re sad a lot right?

    2. 8.2
      Scott F

      You may find this interesting; it’s a sample report from a Conners Continuous Performance Test, which assesses impulsivity and inattention (the two core symptoms of ADHD). I wish I could find the papers relating to this, but I don’t have good academic search skills. No doubt the papers will have more information on baseline attention and impulse control, and how much ADHD differs.

      On the matter of preferring drugs to therapy, ADHD is more like bipolar and schizophrenia, in that it responds very well to medication (depression being the canonical “tends not to be solved by medication alone” condition). There are three main drugs (Ritalin, Adderall, Strattera); you go on one of the stimulants, then the other, and then Strattera, and by this point 90% of patients have found a medication that’s effective.

      Given that brain damage in the frontal lobe causes the same symptoms, ADHD is strongly genetic, and brain scans commonly show an “ADHD pattern” (blood flow / metabolism in frontal lobes decreases when the patient tries to focus; in normal patients it increases), it seems likely that ADHD is basically a neurological condition, and so we wouldn’t expect it to be very amenable to therapy. There is suggestive (but not definitive) evidence that therapy basically only helps people develop coping mechanisms (as opposed to actually reducing the severity of the disease).

      1. 8.2.1
        jesse

        thanks Scott F. Yes, interesting read.

      2. 8.2.2
        jesse

        After reading that it gives me more confidence that therapists aren’t just pulling stuff out of a hat; :-) though I still think there would be methodological problems (and there’s a larger question of whether the whole thing is seriously culture-biased, but that’s a whole other kettle of fish) it at least gives some quantitative criteria.

  9. 9
    thetalkingstove

    That second monologue contains a number of characteristic cognitive distortions associated with depression, such as all-or-nothing thinking (I have to have a partner or there’s no point in even living), disqualifying the positive (the good aspects of my life are irrelevant; it’s all bad because I’m single), mind-reading (everyone must be pitying me), fortune telling (because I don’t have a partner now, I will never have one), catastrophizing (something bad will happen to me and I’ll die alone in my home because nobody will help), personalization (it’s completely my fault that I don’t have a partner; none of it comes down to chance or being in the wrong environment or anything else), and emotional reasoning (I feel like a failure because I’m single; therefore I definitely am a failure).

    Thank you, Miri. I know this isn’t the point of the article, but as a single person currently going through a bout of depression and regularly thinking and feeling almost all of these things it’s quite comforting to see them identified, rightly. as over the top. I know I’m not thinking straight when I’m like this. Making that knowledge *feel* true is a challenge, though.

  10. 10
    Doug S.

    http://xkcd.com/167/

  11. 11
    Ilan

    Let’s also imagine what it would be like if antidepressants were happy pills. If they actually caused happiness, it would feel pretty good to take them, and they would have a high potential for abuse. Yet is there any evidence of this prediction being the current state of things? No, in fact, doctors often have a hard time getting patients to take or continue their antidepressants, and I’ve never heard of anyone with no mental illness taking antidepressants to get happy. If you were not mentally ill and you took antidepressants, I don’t know what would happen because I’ve got both depression and anxiety disorders but I imagine you’d just get a slew of unpleasant side effects like being sleepy all the time and night sweats and being unable to eat grapefruit, which really aren’t worth it unless you’re decreasing your depression symptoms to a point. And this is why people without mental illnesses aren’t out there buying antidepressants on the street. It’d be like taking Advil when you’ve got no pain. You wouldn’t be like “yeah! My body feels so painless right now!” but maybe you’d get an upset stomach. In fact one of the theories for why antidepressants can have the side effect of increasing suicidal behaviours is that when a patient feels a decrease in depression symptoms they might think “is this as good as it gets?” And I think that’s partially due to this idea that antidepressants will just make you feel good. People who’ve never experienced depression might have a hard time understanding this, but there is a difference between not feeling pleasure at this moment and being incapable of feeling pleasure or reward so much that you have difficulty living your daily life.

    1. 11.1
      queequack

      With the disclaimer that I’m not a psychiatrist or a mental health expert (just an informed layperson), I feel like there’s another fundamental misunderstanding that is bound up in this talk of a “happiness pill”. Namely, there’s an implicit assumption that, if depression represents “sadness”, the opposite end of the bipolar spectrum is somehow desirable. This is wrong. Mania is, if anything, even more awful and dangerous than depression. I’m not manic, but I’ve known people who are, and it is very scary to watch. A “happiness pill” that induced mania would lead to quite a few deaths.

      To be at any point on the bipolar spectrum- manic, depressive, or any combination of the two- is to be suffering from a dangerous mood disorder. I’m simplifying here, but what an effective antidepressant does is to remove you from the spectrum entirely, so your default mental state is more-or-less neutral, and then responds reasonably to external stimuli.

      So if a person who is not on the bipolar spectrum were to take an antidepressant, it would likely have no real impact on his or her mental state; they would, however, have to deal with the unpredictable and generally unpleasant side effects.

  12. 12
    queequack

    I definitely agree that one of the hallmarks of depression is the lack of any proximate cause; you might retcon one into existence, but that’s not the same thing, obviously.

    I might also add that, speaking for myself, I’m generally aware that I’m behaving irrationally; I’m fully cognizant of the fact that some of the things I think and even say are ridiculous, inappropriate and ultimately a product of mental illness as opposed to whatever flimsy justification I knowingly bullshit myself with.

    As you said, everyone suffers from cognitive distortions to a point, but in your “healthy” thought process, they are minor enough that they can genuinely go unnoticed. In your “depressed” example, on the other hand, the distortions are so blatant that it’s not really possible to be completely unaware of them. It is a spectrum, but I would argue that there is a difference in kind here, not merely in degree.

  13. 13
    F [i'm not here, i'm gone]

    Thank you!

  14. 14
    wscott

    But only in the second example do these irrational thoughts become all-encompassing.

    It seems to (layman) me like that’s the key point. I can honestly say I’ve had your “depressed” conversation in my own head at various times – I suspect a lot of us have. But it was a temporary thing, and I was able to shake it off and get on with my life. So maybe depression is less about what you’re thinking and more about whether or not you’re able to stop thinking it?

    (Medication might help too, but in a case like this I’d personally recommend therapy first.)

    This touches on something that concerns me about psychiatry as currently practiced, which is that medication and therapy too often seem to be handled as separate spheres of influence rather than as two prongs of a coordinated treatment plan. My friends/family with mental illness tell me they go to their psychiatrist to get pills, and to their therapist for therapy, but there seems to be little-to-no coordination or communication between the two. I don’t know how representative my anecdotes are, so I’d be curious to hear your thoughts on the matter?

  1. 15
    We’re not looking for excuses | The Compassionate Language Learner

    […] living with depression that really resonates with me, and I think there’s a lot of wisdom in Depression Is Not Sadness (Again): those are not bad starting […]

  2. 16
    Depression and Self-Gaslighting » Brute Reason

    […] Cognitive distortion is also a term you probably know. It refers to a set of maladaptive mental habits that people with mental illnesses tend to have. (The Wikipedia list is useful, and I discussed some specific examples in this post.) […]

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