Thank you, Dr, Pies, for this gentle reminder.

The medieval philosopher Boethius observed that, “Good fortune deceives; adverse fortune teaches.”

In my life and in my practice I also find that facing, taking responsibility and overcoming adverse fortune bonds us closer to our loved-ones and shores up self-esteem.

Which reminds me of another quote, “That which does not kill you makes you stronger.”

Thanks, Dr. Aletta–A related saying I have always liked comes from the great physician, Maimonides: “A life of ease destroys bravery.” Our troubles present us with an opportunity to show courage! —Best, Ron Pies

Thanks, Natalie, for your kind note. Yes–the teachings reflected in this piece ought to be “obvious”, yet we all seem prone to forget them, nearly every day. A professor of mine in college–a renowned biochemist–used to teach us about the TAGFU principle in science: Troubles are Good For You. I never really got it back then, and even now, I need to be reminded from time to time! —Best, Ron Pies

Mr. Mermelstein raises a difficult issue: how does a patient who is not doing well under a doctor’s care ensure that he or she gets the right kind of help? Patients are understandably reluctant to bring up the issue with their doctor, for fear of being seen as a “complainer”, or of “insulting” the doctor. And yet, it is every patient’s right to get the best care possible.

In Mr. M’s case, it would be reasonable to say to his doctor, something like, “Doctor Jones, I appreciate your help and care, but I need to tell you that I’m still not feeling well, and I would like discuss other treatment options with you. I also have some concerns about my medications, and would like to get a “second opinion” on them. Would you be able to arrange a consultation with a colleague who specializes in this area?”

A good doctor should not react angrily or defensively to this–if he or she does so react, it may be time to find another doctor. A good place to start for referrals is with your family doctor or general practitioner, if you have one. Another good source for referrals is a near-by medical school department of psychiatry. You can ask to speak with the department head, or with the director of psychiatric nursing–very often, it’s the nurses who will give you the best tips on the best doctors! You can also contact your state’s psychiatric society for specialists in, for example, mood disorders. Sometimes, medical centers with specialized “mood disorder clinics” can be the most helpful resource when depression or related conditions have been resistant to multiple treatments. By the way, psychotherapy is a very important element of treating depression, so I would by no means restrict my questions to medication issues.

In some cases, a psychiatrist can provide both medication and psychotherapy; however, the trend in recent years (not necessarily a good trend, in my view) has been to “split” treatment between the psychiatrist, who prescribes medication, and a therapist who provides psychotherapy. There are pros and cons to this model, in my view. Nurse practitioners can also be very helpful, but in a case of treatment-resistant depression, I would try to find a medical specialist in mood disorder treatment. It is very important that the right diagnosis be made in the first place; for example, ruling out an underlying medical disorder or a bipolar mood disorder. I hope this is helpful for Mr. M. and others in a similar situation. –R. Pies MD

Thanks to Vern Metcalf, D. Reiser, and Jez for their thoughtful comments. However, I would like to clarify the message of my piece, realizing that the point is not easy to formulate convincingly. It was not my intention to show how someone can “make” himself or herself “feel good”, or to suggest that we should candy-coat our problems by denying that they are serious–they often are very serious, and even life-threatening!

Nor does my argument have to do with being “pious” in any religious sense. Rather, it has to do with gratitude, and how cultivating gratitude allows one to find solace and comfort, even in the face of very serious problems.

And, yes–in the strongest version of this argument, which I know not everyone will endorse, one can even be grateful for one’s problems! The philosopher Nietzsche referred to this as “amor fati”–loosely translated, “being content with the cards life has dealt you.” This attitude is not the result of some “feel-good”, put-on-a-happy face pose that one adopts. It comes from the deep-seated realization that one has problems solely as a result of being alive–and that being alive is worthy of tremendous gratitude. In one sense, this is all very obvious; yet how many of us actually feel gratitude, much less cultivate it, on an every-day basis?

I’ll put the point in a more colloquial way, based on a true story. I was in a pizzeria one day many years ago, and heard the guy behind the counter say to a customer, “Have a good day!” The customer smiled and replied, “Any day that begins above ground is a good day!” I have always remembered that homely but life-affirming adage, which expresses something of the sense of gratitude I have in mind.

I’ll sign off and let our readers take it from here. –R. Pies MD

Hello, Heidi–Thanks for your important point. The “advice” (really, observations) in my blog was not intended as a therapeutic intervention for someone who is significantly depressed, as you surmised. You are right that in a state of severe depression, the person’s frame of mind would likely not tolerate the kind of “perspective” my piece suggests. Certainly, no competent therapist would say to a severely depressed patient, “You know what? You should be grateful for your problems–it means you are alive!” At the risk of sounding flippant, that approach would not be much better than the one used by the therapist in the old joke:

Patient: Doctor, I lost my job, my wife, my dog, and my house, all within a month’s time.

Therapist: Well, it could have been worse.

Patient: What? Doctor, how could it possibly have been worse!?

Therapist: It coulda been me!

I will just add, Heidi, that even though the perspective in my piece would not likely be appropriate for the severely depressed person, it has some similarities to the approach used by Aaron Beck, Albert Ellis, and other cognitive therapists, in that it aims at changing the person’s perspective or “world view”. With a depressed patient, however, it is first important to create an atmosphere of empathy and non-judgmental acceptance. It is only when the therapeutic alliance is strong, and the patient can trust the therapist, that a “rational” examination of the patient’s underlying assumptions and beliefs can be gently challenged. For those who want to learn more about these therapeutic approaches, I recommend Ellis and Harper’s classic (1961) book, “A Guide to Rational Living”. David Burns’ “Feeling Good” is also a good source on this approach.
–R Pies MD

Hi, Daniel–I know things look hopeless from where you stand, but I can tell you that you are not alone, and that you can feel better if you get some professional help. Please start by seeing your family MD, or nearest emergency room, ASAP. If you can’t talk to your wife about all this, talk to a friend, or call one of the local suicide hotlines in your area [suicidehotlines.com]. Your family needs you to see this through…you can do it!–Best wishes, R. Pies MD

Katrin, many thanks for sharing your brave and hard-won insights, and for your kind words. Let us hope that all who are in need of support and solace will make use of your gifts. –Best regards, R. Pies MD

Thanks again for the kind note, Katrin. And, yes–I did find some of those comments on Beliefnet quite disappointing, particularly since some were apparently from my “colleagues”!

I personally find it distasteful that medical professionals write blogs and emails under “pen names” or clever pseudonyms–especially when they use their anonymity to attack other professionals. In my view, if a physician or other health professional says something he or she wants people to know about, the responsible thing is to use one’s name. (I do understand that, for reasons of personal security or fear of stigma, some non-professionals do not want to leave their full names–I hold my medical colleagues to a different standard).

But, then–in the larger scheme of life’s brief span, “this, too, shall pass.” And–to return to my theme–”Having problems means being alive!”

By the way, in my book,Katrin,you are quite an important person! –Best regards, Ron Pies MD

Hi, Katrin–Good to hear from you! Please excuse my obtuseness, but I am not quite sure what comments or person you are referencing–or whether you wanted to raise a specific question. Sorry–I’m sure I ought to understand, but if you care to clarify, I’ll try to respond in a more useful way! –Best, Ron Pies MD

Hi, again, Katrin–Please know that the one who needs to be in my thoughts and prayers will be. –Best regards, Ron Pies