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.

Depression is Not Sadness

[Content note: depression, suicide]

Yesterday I came across the story of Junior Seau, an NFL linebacker who committed suicide on May 2. He shot himself in the chest and was found in his home by his girlfriend. Although little is known of Seau’s mental health leading up to his death, he had apparently suffered from insomnia for the last seven years of his life.

Sportswriter Chris McCosky wrote a beautiful column in the Detroit News about Seau’s death and continuing ignorance about depression and suicide. In the column, McCosky shares his own experiences with depression and suicidal thoughts and laments how difficult it is to explain them to people. He notes, as I’ve noted before, that one common reaction that non-depressed people have is to wonder what the hell we have to be so sad about. He writes, “It’s almost impossible to talk about it to regular people (bosses, spouses, friends). They can’t fathom how somebody in good physical health, with a good job, with kids who love them, who seems relatively normal on the outside, can be terminally unhappy.”

The unbearable frequency at which McCosky and I and probably everyone else who tries to talk about depression get this response could be a testament to the fact the most visible symptom of depression is usually sadness. So that’s the one people latch on to: “What do you have to be so sad about?” “Cheer up!” “You have to decide to be happy!”

Because of the sheer obviousness of our sadness, we’re often forced to try to use it to describe depression. We say that we’re just extremely sad, or unhealthily sad, or a different kind of sad. It’s sadness that never goes away like sadness is supposed to. It’s sadness that’s out of proportion to the troubles that we face in our lives. It’s sadness that we can’t stop thinking about. For those of us with bipolar or cyclothymic disorder, it’s sadness that comes and goes much too quickly.

And it is. But the truth is that sadness actually has very little to do with depression, except that it is one of its many possible symptoms.

Based on the diagnostic criteria for depression, you don’t even need to be chronically sad to be considered “depressed.” Anhedonia, which means losing the ability to feel pleasure from things that you used to enjoy, could be present instead. Under the formal DSM-IV definition, you must have at least five of nine possible symptoms to have major depression–and one of the five must be either depressed mood or anhedonia–and only one of those symptoms involves sadness. (If you so some very basic math, you will notice that this means that two people, both of whom officially have major depression, might only have one symptom in common. Weird, huh?)

So, even if your particular depression does include sadness, it’ll only be one of many other symptoms. The others might be much more painful and salient for you than the sadness is. Some people can’t sleep, others gain weight, some think constantly about death, others can’t concentrate or remember anything. Many lose interest in sex, or food, or both. Almost everyone, it seems, experiences a crushing fatigue in which your limbs feel like stone and no amount of sleep ever helps. Then there are headaches, stomachaches, and so on.

So, depression doesn’t necessarily mean sadness to us. (And, a gentle reminder to non-depressed folks: being sad doesn’t mean you’re “depressed,” either.)

Depression is not sadness; it’s an illness that often, though not always, involves sadness. No amount of happy things will make a depressed person spontaneously recover, and, usually, no amount of sad things will make a well-adjusted person with good mental health suddenly develop depression. (Grief, of course, is another matter.) And sadness, on its own, does not cause suicide.

We need to start talking about mood disorders as disorders, not as emotional states. McCosky writes:

Junior Seau wasn’t sad when he pointed that gun to his chest. He wasn’t being a coward. He wasn’t being selfish. He was sick. I wasn’t sad when I thought about swerving into on-coming traffic on Pontiac Trail some 20 years ago. I was sick.

What he’s saying is that people don’t kill themselves because they’re sad. They kill themselves because they have an illness that, among other things, makes them feel sad. It also makes them feel like their life is worthless, like they’re a burden to others, like death would be easier, and all the other beliefs that lead people down the path to suicide.

There is a tendency, I think, to assume that people are depressed because they are sad. A better way to look at it is that people are sad because they are depressed. That’s why, even if we could “turn that frown upside down!” and “just look on the sunny side!” for your benefit, it would do absolutely no good. The depression would still be there, but in a different form.

Junior Seau did not leave a suicide note, so nobody will ever know what he was thinking when he died. I would guess, though, that he was thinking about much more than just being sad.

Death to Debbie Downer

Made famous by SNL.

I propose a moratorium on the term “Debbie Downer.”

“But whyyyy?” you might argue. “Those negative people are so annoyinggg!”

Perhaps. But I think we need to stop using that phrase, for several reasons.

The first thing I think of when I hear the phrase “Debbie Downer” in one of the contexts it’s most commonly used (i.e. “Oh, don’t mind him, he’s just a Debbie Downer”; “Why are you being such a Debbie Downer?”; etc.), is that it’s a reflection of our culture’s dismissal of anyone who doesn’t have a smile plastered all over their face at all times.

After all, isn’t that such a dismissive thing to say? When one calls someone a Debbie Downer, they’re implying that this person’s thoughts and opinions aren’t to be taken seriously. It means that rather than taking the time to figure out why someone’s saying all these negative things, they’re just going to write them off with a convenient alliterative term.

Second–and if you read this blog regularly, I’m sure you know where this is going–“Debbie Downer” is often used as a disparaging term that basically means “person with a mental illness.” In that context, it’s not only insulting, but inaccurate. Depression and related disorders don’t simply make people “negative.” They make them hopeless, joyless, and, at times, suicidal. You don’t really know if the frustrating person making pessimistic comments all the time is actually a pessimist, or actually struggling with a debilitating illness. So why assume?

~~~

“But wait!” you might say. “How dare you tell me how to talk? Free speech!”

Absolutely. Unlike certain more Leftist people, I would never argue that one should “ban” words just because they offend people. But look at it this way–if your friend or family member is being negative and you call them a “Debbie Downer,” all you’re doing is shutting them down and making them feel like you don’t really care about how they feel. Is this really what you want them to think? No? Then choose your words more carefully.

As for how I think one should respond to overly negative people, it’s not the way we’re used to doing it. Many people respond by trying to argue with or counteract the negative statements with positive ones, or sarcastically asking “Don’t you have anything nice to say?”, or snapping something like, “Stop complaining.”

(Our culture places a huge stigma on anyone who expresses anything even closely resembling a complaint. What else would explain the proliferation of special purple bracelets given out by various groups that members are required to wear until they have stopped “complaining”? My high school band used them. Rather than feeling free and happy in all this new-found positivity, I felt shut up and silenced, like my opinions–negative or otherwise–don’t matter.)

You’ve by now probably gathered that I think all of this is not only an exercise in futility, but actually quite damaging to relationships. Unsurprisingly, people don’t like to feel belittled and rejected.

Next time, try this simple question: “What makes you say that?”

You may be surprised at the response you receive.

~~~

The last point I wanted to make regarding this phrase is that it reveals something very interesting about our culture. We view others’ negative emotions as some sort of personal insult or attack, and we respond accordingly. Rather than either addressing the person’s issues or ignoring them, we instead allow them to bring us down–hence the term “Debbie Downer.” The response that many a depressive (or simply a sad person) has encountered is, “Why do you have to ruin my mood all the time? Why do you have to bring everyone down all the time?”

My response to that is, why are you letting someone else’s problems ruin your mood?

One might argue that it’s “impossible” to be in a good mood if someone around you is not. This is pure bullshit. In fact, I’m going to propose something radical–what if it’s entirely possible to be in a good mood despite the presence of “Debbie Downers?”

I believe that unless you yourself have a psychological problem that keeps you from being in control of your own emotions, nothing can keep you from being in a good mood if you want to be. So perhaps we should stop blaming our own bad moods on other people and acknowledge that we have control over them instead.

The great irony here is that the people bitching and moaning about “Debbie Downers” are usually those very same people who tell those of us with mental illnesses that we just have to “look on the bright side” and “stop letting the little things bring you down” and all those tropes. Perhaps they should take their own advice.

A sad person isn’t a personal insult to you, nor an insurmountable barrier to your own happiness. Next time you encounter one, try a little compassion instead of sarcastically putting them down with a cliched phrase.