Thank you very much!

Sabina

We are looking forward to translate this article for further publishing in
our magazine. It is really an important, painful and hot topic and the
discussion initiated will be, as we believe, very helpful and interesting
for our readers.

I will be very thankful if we could use your text.

Thank you very much in advance,

Sabina Safarova

Move away from the edge. Slow shifting of legs, not a walk, more a shuffle, idling away from the ledge. No peering over, that wouldn’t be wise, shuffle and shift away. The canyon landscape, with distant plateaux. The dry powdery soil, red and mobile as the feet slither, shuffle and shift. There is a trace behind. Very clear and distinct, wider than that left by mere walking. The shuffle trace, the slow movement of the steady unsure. We’re moving away from the edge, but we’re going to take it slowly. We’ve been lying on the edge for so long, sleeping on the ledge, the tiniest movement meaning certain plummeting, plunging straight down. Have we fallen? Can’t really say. We’ve been more in a frozen state, petrification of body and spirit. Stand still! Don’t move! Now inch your way away. The precipice is no place to play. We’ve been sliding buttocks, inching fingertips on fragile crumbling earth. Then to crawl, silently, with soft sobbing. But now on foot, shuffle shuffle shuffle. Swish, sift, soft red soil. Don’t look back with the loving morbid fascination. Where you were is not a place to linger after. But the lessons… The lessons of the precipice are dry, gritty red soil between teeth, up above gums, powdered on and in eyes, under and around nails, cosmic blood moons to scratch and scrape, an internal screaming. Breathing dust and grit, coughing, suffocating. The ledge is no school, its master is cruel with massive claws and a savage appetite. He will teach you nothing. Shuffle away sturdy footed friend. Shuffle shuffle, shift. Feel the earth compact. It wants to carry you. Shuffle shuffle shift. Can I lie down here for a moment? Will the earth break away? Can I caress the soil? The earth pillow my prayer. Now I lay me down to sleep. I pray the lord my soul to keep. If I shall die before I wake. I pray the lord my soul to take. Shuffle shuffle shift. The sheets of dirt warm my new bed. It’s yonder precipice that will need to find a new friend, for I shall shuffle shuffle shift away.

The ancient Stoics (whom I discuss in my book, “Everything Has Two Handles”)would largely agree that while we don’t have much control over the onset of a bout of depression, once we have it, we have considerable freedom as to how we “view” it. We can choose to view it as “the end of the world”, a catastrophe, etc.; or, we can view it as an unfortunate but potentially useful experience.

And, as I’ve said all along, I do believe people can learn useful lessons from their depression. What I rejected from the beginning was the notion that severe, clinical depression is “adaptive” in some evolutionary sense. Stay tuned, in Psychiatric Times, for a more complete statement on this from Professor Jerry Coyne, an expert in evolutionary biology.

I do agree that by “re-framing” depression, we can help ourselves emerge from it, and that we need not feel like helpless victims in the face of depression. At the same time, we need to guard against telling severely depressed people that they really ought to cherish the experience as “valuable” in some way–that will usually backfire, in my experience.

There is a delicate balance to be achieved in working with the depressed person: acknowledging that it is a painful, disruptive, and maladaptive mood state; and yet, also encouraging the person to look at the depression from other perspectives, and to avoid “catastrophizing” about it.

As the Stoic philosopher Epictetus reminds us:
“Everything has two handles–one by which it may be borne, another by which it cannot.”

Best regards,
Ron Pies MD

I suffered pretty bad depression that most would call the “regular” kind. The last depression was actually chemically induced by interferon (I was both homicidal and severely depressed). I didn’t do anything “wrong”, I am actually pretty optimistic. Both led to new insights in the world and I would consider them positive influences, now. I guess I just kept getting them until I “got” it. I also believe that I “got” my soul out of it rather than losing it. But that revelation did not come for a couple of years and after I had stopped seeing a professional. This could be happening to people who have stopped coming into your office and maybe this data would account for the small percentage of people in your data set who view this experience with positive benefit. It could also be suggestion, no-placebo or an ontological view on your part.

My mother on the other hand is one of those “my soul is missing” people. I hear her attention getting behaviour as well as the typical negative thinking associated with this and she would not change it to save her life.

It is interesting that you used the word “wrong” because I just can’t believe in such a thing any more. I have actually found this belief prevalent in almost all of the depressives I have come in contact with (as well as most educated people). My data set may be after they have stopped seeing you, hence my weighted data.

All of this would be rendered mute by someone missing actual pieces of his or her brain or having major physical abnormalities. But I don’t think that was the point of the article.

I wondered the other day what the cases of depression were among cavemen who worked for an hour or so a week and slept as much as they felt like. I would have to say that it would be lower if not non-existent.

I guess my main point here is that I, and multitudes of others that I have worked with, have found a “re-framing” mechanism that has the depression occur as the most valuable experience in our lives. The people who cannot do this for whatever reason seem to still suffer. It could be the patients own “view” (missing soul, best thing ever) of the depression that has it reoccur. I think Dr. Pies would agree that we are responsible for our view of the depression and our life.

Here is a rough analogy. Fever can sometimes be an important signal that tell us something is “wrong”, and can alert us to take constructive action, such as seeing a doctor. But when fever goes beyond a certain point, it is no longer merely an “alarm signal”–it functions as a disease in itself, and can sometimes even be lethal if it gets too high.

Similarly, a brief period of depressed mood can often be a useful signal that something is wrong with our way of going about things: maybe we are too sensitive to criticism, or perhaps we tend to see everything in catastrophic terms. These are aspects of ourselves that we can change, as Mr. Baxley might agree.

But sometimes, a bout of severe depression can occur “out of the blue”–even when we are doing everything “right” and have no particular complaints or problems with our life. No doubt, there are genetic, biochemical, and environmental factors that can converge to produce these more “endogenous” (coming from within) and severe bouts of major depression. Individuals with these severe forms of depression are not trying to get “attention” , nor do they necessarily see themselves as helpless victims. Many realize that they have a role to play in their own recovery, such as entering into psychotherapy.

But they should not be blamed for their depression, or given the impression that they are just seeking attention. It is not simply a matter of lacking “will power”, anymore than someone can “will” themselves out of having a heart attack. Those with serious bouts of major depression deserve our love, support, and best professional efforts at helping them recover.

Ronald Pies MD

People need to start taking responsibility for their own emotional states and stop being a victim because it pays off so well in attention from others!

Maybe “existential depression” has some sort of benefit, but I don’t know because for me this tends to accompany my Major Depression or lead to it.

Hello, All–I appreciate some of the very thoughtful responses to my article that have come in recently, and I’d like to refine and clarify a few points.

First, as regards the use of the phrase, “Depression’s Upside”–this was originally used by Mr. Lehrer in the article I criticized. I don’t know if he personally chose the title, or if–as is often the case in publishing–some editor at the NY Times chose it.

Second: in calling for the recognition of major depression as a serious and “non-adaptive” illness, I am not advocating the use of medication to treat it–nor have I any particular investment (financial or emotional) in the use of such medication. I do believe, as a matter of empirical findings, that the most severe, “melancholic” types of major depression usually do require medication as a component of comprehensive treatment (i.e., along with “talk therapy”).

Finally, I do not in any sense with to deny that even severe depression can–for some individuals–bring “moments of enlightenment”, insight, or even wisdom. Several comments above indicate that, for some, this may indeed be the cas–though I strongly suspect that such insights usually come after the worst of the depressive bout has subsided.

The claim that depression may sometimes lead to important insights or emotional-spiritual growth is not the same claim as Mr. Lehrer was making, nor is it the same claim as that made in the “adaptive rumination hypothesis” (ARH). The ARH holds that the state of depression itself is associated with a certain sharpening of analytic skills, by virtue of the “rumination” that it permits, and that this is “adaptive” in an evolutionary sense. I stand by my claim that there is no credible scientific evidence for this; and that, on the contrary, the severely depressed person is at a severe cognitive (and probably, evolutionary)disadvantage.

Once again, we need to avoid linguistic confusion. Thus, what some have called “existential depression” may not be closely related at all to the kind of major depressive episode defined by the DSM-IV. I happen to believe that there is a kind of irreducible sadness to life as a human being–akin to what the Buddhist tradition calls “dukha”. For some, this kind of “sorrow of being” may indeed inspire profound insights, poetry, and philosophy: perhaps the philosophers Kierkegaard and Schopenhauer might be examples of this ability to transcend dukha, and to produce truly enlightening philosophy and ideas.

I do not see this “existential depression” as equivalent to the kind of life-sapping, spirit-killing major depression described by writers such as William Styron, in Darkness Visible. There is a big difference between periodic “depressive thoughts” and a full-blown episode of major depression.

I hope this clarifies some aspects of my argument. I also have a piece in the current issue of Psychiatric Times, entitled, “Depression is a Thief, Even When We Learn from It”, that elaborates some of these points.

Thanks again to all who contributed to this discussion. –Ronald Pies MD

First, as regards the use of the phrase, “Depression’s Upside”–this was originally used by Mr. Lehrer in the article I criticized. I don’t know if he personally chose the title, or if–as is often the case in publishing–some editor at the NY Times chose it. I agree that the term “upside” is simplistic and inappropriate.

Second: in calling for the recognition of major depression as a serious and “non-adaptive” illness, I am not advocating the reflexive or unthinking use of medication to treat it–nor have I any particular investment (financial or emotional) in the use of such medication. I do believe, as a matter of empirical findings, that the most severe, “melancholic” types of major depression usually do require medication as a component of comprehensive treatment (i.e., along with “talk therapy”).

Finally, I do not in any sense with to deny that even severe depression can–for some individuals–bring “moments of enlightenment”, insight, or even wisdom. Several comments above indicate that, for some, this may indeed be the cas–though I strongly suspect that such insights usually come after the worst of the depressive bout has subsided.

The claim that depression may sometimes lead to important insights or emotional-spiritual growth is not the same claim as Mr. Lehrer was making, nor is it the same claim as that made in the “adaptive rumination hypothesis” (ARH). The ARH holds that the condition of major depression itself is associated with a certain sharpening of analytic skills, by virtue of the “rumination” that it permits, and that this is “adaptive” in an evolutionary sense. I stand by my claim that there is no credible scientific evidence for this; and that, on the contrary, the severely depressed person is at a severe cognitive (and probably, evolutionary)disadvantage.

Once again, we need to avoid linguistic confusion. Thus, what some have called “existential depression” may not be closely related at all to the kind of major depressive episode defined by the DSM-IV. I happen to believe that there is a kind of irreducible sadness to life as a human being–akin to what the Buddhist tradition calls “dukha”. For some, this kind of “sorrow of being” may indeed inspire profound insights, poetry, and philosophy: perhaps the philosophers Kierkegaard and Schopenhauer might be examples of this ability to transcend dukha, and to produce truly enlightening philosophy and ideas.

I do not see this “existential depression” as equivalent to the kind of life-sapping, spirit-killing major depression described by writers such as William Styron, in Darkness Visible. There is a big difference between periodic “depressive thoughts” and a full-blown episode of severe major depression.

I hope this clarifies some aspects of my argument. Thanks again to all who contributed to this discussion. –Ronald Pies MD

(Rhetorical) What of existential depression? My question to you is how can one NOT benefit from depression unless he or she is merely just feeling bad for his or her self? Forgive me if I sound callous.

J Clin Psychiatry. 2009;70 Suppl 5:7-11.
Omega-3 fatty acids in major depressive disorder.

Freeman MP.

Center for Women’s Mental Health, Massachusetts General Hospital, Simches Research Building, 185 Cambridge St, Boston, MA 02114, USA.

Patients with major depressive disorder have high rates of cardiovascular disease and other medical comorbidity. Omega-3 fatty acids, particularly those found in fish and seafood, have cardiovascular health benefits and may play an adjunctive role in the treatment of mood disorders. However, existing studies on omega-3 fatty acids in depression have limitations such as small sample sizes and a wide variance in study design, and results regarding efficacy are mixed. The preponderance of data from placebo-controlled treatment studies suggests that omega-3 fatty acids are a reasonable augmentation strategy for the treatment of major depressive disorder. More research is necessary before omega-3 supplements can be recommended as monotherapy for the treatment of depression. For many individuals with major depressive disorder, augmentation with omega-3 fatty acids should be considered, as general health benefits are well established and adjunctive use is low risk. (c) Copyright 2009 Physicians Postgraduate Press, Inc.