DEPRESSION IS NOT SADNESSby Monica A. Frank, Ph.D.
A serious problem exists with the public's understanding of depression. The problem occurs because of the clinical term "Major Depression" and the general use of the word "depression." One of the definitions in the Merriam-Webster dictionary indicates that depression is "a state of feeling sad." Therefore, the general public typically defines "depression" interchangeably with "sadness" as in "I'm so depressed today." The tendency, then, is to assume that clinical depression is just extreme sadness or the inability to handle normal stress and sadness of life.
This assumption is not only wrong but it is a disservice to all individuals who experience one of the clinical forms of depression: Major Depressive Disorder, Dysthymic Disorder, Depression NOS (Not Otherwise Specified), or Adjustment Disorder with Depression. With each of these disorders, the symptoms manifest with varying degrees of intensity and cause varying amounts of dysfunction. However, to simplify this discussion we will focus primarily on Major Depressive Disorder and Dysthymic Disorder.
The hallmark of Major Depressive Disorder is the amount of daily dysfunction that it causes. A person with this disorder may be unable to work, go to school, or socialize. Sometimes they are unable to engage in basic self-care routines such as showering or taking their medicine. Most frequently, severe sleep disturbance is present along with eating disturbance particularly lack of desire to eat. The individual reports extreme fatigue, dysphoria (low mood), and lack of interest in usual activities. The most serious symptom of Major Depressive Disorder that is frequently present is suicidal ideation (wishful thoughts of death) which is sometimes present with suicidal intention. To diagnose Major Depressive Disorder, the above symptoms must be present a minimum of two weeks.
Dysthymic Disorder is less well-known among the general public but often more problematic due to the lack of understanding as a result of the lower intensity of symptoms. Dysthymic Disorder is a low-grade but chronic depression. The extreme dysfunction characteristic of Major Depressive Disorder is not present but the chronic nature indicates that the mild to moderate depressive symptoms have been present for a minimum of two years.
One of the predominate differences from normal emotion is that depression typically is more of a numbness of emotion rather than an expression of emotion. In fact, in many cases, if significant active emotion is present such as frequent crying the individual may be more likely dealing with the normal emotions of grief or loss. However, this can become confused due to the accurately perceived loss an individual feels when suffering from the depressive disorders. In other words, a person suffering from depressive symptoms may also feel grief because the depression has imposed limitations and losses upon his/her life. For example, a woman's husband may leave her because he can no longer tolerate her inability to take care of herself, her sad and irritable mood, and her lack of interest in life. As a result, she not only experiences a depressive disorder, but she also experiences grief due to the losses caused by the disorder.
Another key difference between depressive disorders and normal emotions is that the core symptoms of depression are physical. The individual's physiology is in a lowered, or depressed, state. The best way to describe this state for someone who hasn't experienced it is to imagine when you have had a low-grade virus that causes general fatigue, a feeling of malaise (bodily discomfort or unease), slower thought processing, lack of interest in usual activities, lack of appetite, and excessive sleeping or inability to sleep. These symptoms are similar to what a depressed person feels continually without relief. Now imagine that no matter what you do, those symptoms don't dissipate over time. The inability to change those core symptoms often lead to the secondary symptoms including frustration, hopelessness, feelings of failure and behaviors including social isolation, avoidance of many activities, and lack of motivation.
In addition, sleep disturbance is a central feature of most depressive disorders, particularly Major Depressive Disorder, whereas normal emotions don't tend to effect sleep for significant periods of time. Even though intense grief may disrupt sleep patterns temporarily, it does not tend to be as intense or chronic as the sleep disturbance with Major Depressive Disorder.
Finally, normal emotion does not cause the severity of disruption to normal daily activities particularly not for any prolonged period of time. The individual remains able to engage in normal work or school-related activities. Even intense grief from uncomplicated bereavement does not tend to cause serious disruption to necessary activities for longer than a couple weeks. A person may not desire to engage in most activities but they have the ability to do so.
Most of the clients I treat for depressive disorders also feel guilty due to the belief that they "should" be able to handle their emotions better. After all, "other people are able to handle loss, grief, sadness." They reason that if they are so seriously affected they must be weak-willed or not trying hard enough. These feelings of guilt only serve to make the individual worse due to feelings of inadequacy. To refer again to the above analogy of being sick with a low-grade analogy, imagine that not only are you suffering due to the illness but you also believe that you are sick because you didn't take care of yourself well enough, you didn't exercise enough or eat the proper foods. Now, you might react to these statements by saying "That's ridiculous! Sometimes you can do all the right things and you still get sick!" And that is exactly my point. An individual with a depressive disorder doesn't have any more control over the illness of depression than someone with a virus; there are health practices that are beneficial but such practices don't eliminate illness completely.
Another critical reason to differentiate depressive disorders from normal emotion is that others often blame the individual with depression. "If only you would look at things more positively" or "If you'd just get out and do things" or "You can do this, you're just not trying" are messages the depressive person frequently hears. These messages only contribute to the negative self-talk, feelings of failure, and hopelessness the individual already feels. Research with dogs many years ago demonstrated that if an animal believes that it can't control its circumstances, it gives up and quits trying. Martin Seligman and Steve Maier (1967) labeled this behavior "learned helplessness" and hypothesized that the lack of control contributes to the symptoms in depressed individuals. One way this process may occur is that if the individual believes he/she should be able to control the symptoms of depression if they just tried harder, but no amount of effort reduced the depression, the individual would eventually give up. Therefore, blaming the individual with depression is only likely to cause the individual to quit trying.
Finally, if I can help an individual with depression recognize the symptoms of depression as due to the physical illness of depression we can often begin improving the depressive symptoms. You may ask "How can that be? You just said that the person doesn't have control over depression and isn't to blame." Which is true. However, cognitive-behavioral therapy can assist with improving perceived control which leads to improved self-care behaviors. If the individual doesn't feel guilty and like a failure, they become more able to take steps that can help reduce the depressive symptoms. I explain to clients that the treatment of depressive illness is similar to treatment of chronic pain: if a person examines his or her symptoms without negative self-evaluation he or she may be able to take reasonable steps towards recovery. For example, we know that exercise reduces depressive symptoms (Leith, 1994). However, exercise is frequently difficult for individuals suffering depressive disorders. If the individual blames him or herself and thinks "If I wasn't so weak and lazy I could get over this depression" he or she is less likely to try exercise. However, if he or she thinks "I have a physical illness that makes it difficult for me to exercise, but if I recognize my limitations and start a little bit at a time I'll be able to do it" he or she is then more likely to try.
Therefore, a necessary condition for reducing depressive symptoms is to recognize the depressive disorders as a medical condition and to refrain from self-recrimination. As with many other medical conditions, depression can be improved with lifestyle behavioral changes. However, the individual needs to believe in his or her ability to impact the symptoms.
Leith, L.M. (1994). Foundations of Exercise and Mental Health. Morgantown, WV: Fitness Information Technology.
Seligman, M.E.P. and Maier, S.F. (1967). Failure to escape traumatic shock. Journal of Experimental Psychology, 74, 1–9.
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Dr. Monica Frank