Imagine this scenario. Your seven-year old son is riding his bike, and takes a nasty fall. He has a gash on his knee that looks pretty bad, but you get out your first-aid kit, clean the wound, put a little iodine on it, and cover it with a sterile gauze pad.
Two days later, your son complains that his knee hurts a lot and that he “feels crummy.” He didn’t sleep well the night before, and his face seems a little flushed. You remove the gauze pad and notice that his knee is red and swollen, and there is a foul-looking, greenish liquid oozing out of the wound. You get that sinking, “Uh-oh!” feeling, and decide you had better have your family doctor take a look at the knee.
As you are about to drive off, your friendly neighbor buttonholes you and asks where you are going. You explain the whole situation to him. He looks at you like you are from Mars, and says, “Are you nuts? You want this kid to grow up to be a wimp? He is supposed to be in pain! Pain is a normal part of life! We all have to learn how to live with pain. Redness and swelling are normal, after you bang up your knee! Let the kid heal up naturally! The doctor is just going to put him on some damn antibiotic, and you know the kind of side effects those drugs have. Those doctors, you know, they just make money on all those prescriptions!”
Would you feel that your well-intentioned neighbor was giving you good advice? I very much doubt it. Well, it’s the kind of advice some well-meaning but misinformed individuals give, when dealing with the issue of severe grief and depression. In part, this attitude is a remnant of our Puritan roots—the idea that suffering is God’s will, that it ennobles the soul, or that it is just plain good for us!
Now, it is certainly true that life is full of bumps, bruises, and falls. It is also full of disappointment, sorrow, and loss. Not all of these are occasions for a medical diagnosis or professional treatment — most are not. But there are times when a simple cut can become infected, and there are also times when so-called “normal” grief can become a very nasty beast called clinical depression. Learning how to deal with disappointment and loss is part of becoming a mature human being. Coping with loss may indeed be a “growth-promoting” experience, under the right circumstances. But “hanging tough” and refusing to seek help in the face of overwhelming pain — physical or emotional — is an affront to our humanity. It is also potentially dangerous.
The Case of Jim
I recently had an essay published in the New York Times (9/16/08), in which I argued that the line between profound grief and clinical depression is sometimes very faint. I also argued against a popular thesis that says, in effect, “If we can identify a very recent loss that explains the person’s depressive symptoms — even if they are very severe — it’s not really depression. It’s just normal sadness.”
In my essay, I presented a hypothetical patient — let’s call him Jim — who was based on many patients I’ve seen in my psychiatric practice. Jim comes to me complaining of “feeling down” for the past three weeks. A month ago, his fiancée left him for another man, and Jim feels that “There’s no point in going on” with life. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.
I deliberately withheld a lot of important information that any well-trained psychiatrist, psychologist, or psychiatric social worker would obtain. For example: in the past three weeks, had Jim lost a great deal of weight? Was he awakening regularly in the wee hours of the morning? Was he unable to concentrate? Was he extremely slowed down in his thinking and movement (so-called “psychomotor retardation”). Did he lack energy? Did he see himself as a worthless person? Did he feel completely hopeless? Was he filled with guilt or self-loathing? Had he been unable to go to work or function well at home, over the past three weeks? Did he have any actual plans to end his life?
I wanted to make the case ambiguous enough to be suggestive of clinical depression without “clinching” the diagnosis by providing answers to all these questions. (A “yes” answer to most of these questions would point to a serious bout of major depression).
But even given the limited information in my scenario, I concluded that people like Jim were probably better understood as “clinically depressed” than as “normally sad.” I argued that individuals with Jim’s history merited professional treatment. I even had the temerity to suggest that some grieving or bereaved individuals who also show features of a major depression may benefit from antidepressant medication, citing the research of Dr. Sidney Zisook. (If I had to write the piece all over again, I would have added, “Brief, supportive psychotherapy alone may do the job for many people with Jim’s symptoms”).
Well, my goodness! The blogosphere lit up like a swarm of fireflies. You would think that I had advocated the killing of the first-born! I should not have been surprised by the reaction from the “Hate Psychiatry First” crowd, who get their information about psychiatry from Tom Cruise. They wrote me off as either a shill for the drug companies [see disclosure], or someone who was “declaring grief to be a disease.” One of the most irate bloggers opined that my medical license should be revoked!
Nearly all of my colleagues were very supportive and felt that I had made some good points. But a few responses from mental health professionals really surprised me. One PhD-level “bereavement specialist” scolded me for failing to let my hypothetical patient “heal naturally” from his “normal grief”. Never mind that my patient had lost interest in nearly all his usual activities, and sounded vaguely suicidal—to this critic, feeling suicidal was all par for the course and nothing to get too upset about. She spoke of her ten years of experience, and how many people with “normal grief” feel like “not going on” with life. Well, after 26 years of practice, I guess I just lack confidence!
One thing I do know: nobody inside or outside my profession is very good at predicting who will attempt suicide. There is also good research from Dr. Lars V. Kessing showing that suicide rates are not markedly different for those whose depression is apparently a “reaction” to some stressor or loss, versus those with no apparent cause for their depression. And, as I note in my NY Times article, it is not always clear whether a depressed person is “reacting” to some life event, or whether the depression preceded and precipitated the event. For example, the person who insists, “I got depressed after I lost my job” may actually have been depressed while still employed, and may not have been working at her usual efficiency.