Sad, grieving or depressed?
Sad, grieving, or depressed, that is the question. Everyone knows sadness, it has many sources. The frustration of not having what we want or being able to make significant progress toward achieving our dreams or follow through on plans generate sadness. Sadness is a normal reaction and somewhat of a sanctuary until we are ready to try again or change plans.

Grieving is about loss; usually most painfully about the loss of love or a loved one. Even small losses may result in the emotional pain known as grieving. Sadness and grieving respond well to therapy and are most likely to dissipate on their own overtime. These states are often diagnosed inaccurately as depression, they are not. Nor will they respond to antidepressants, because there is no significant chemical imbalance, for the antidepressant to address.

Depression is a whole different thing. Depression may eventually result from multiple underdressed grief and sadness issues that have rotted for so long they have become the homeostatic condition of the biochemistry of individual. In this case antidepressants and therapy are both appropriate. But that’s not the only kind of depression there is. Many people, usually the descendents of biochemically depressed individuals are born biochemically depressed individuals. All the therapy in the world will not do any good. If the person is fortunate they may find antidepressants or a combination of antidepressants that effectively lift their mood and allow them to operate on a whole different, non-depressed, level. These people could also benefit from significant therapy after the depression has lifted, but not until then. Why therapy after the depression has lifted? Because a person who is primarily depressed and has always been primarily depressed will be confronted with whole new ways of being in the world that would benefit from and be supported by a therapeutic relationship. This is the best way to prevent relapse. Rarely is a person who has been depressed for a significant amount of time, that is years or decades, in a financial position to maintain the medication and therapy necessary to stay well.

25 years ago, when I was being treated for depression, I had excellent insurance. I worked for the County of Santa Barbara psychiatric inpatient unit and had access to the best psychiatrist, the best resources. I had the privilege of being a patient of Dr. Joseph Johnson, who would on a weekly basis, spend an hour with me. At that time, that was the standard. I had the best medications and excellent therapy. Consequently, it was one of my most “well” periods. Then came managed care. Dr. Johnson was permitted 15 minutes per patient. He could no longer do psychotherapy; he could no longer even do a decent medication assessment. He went from being a very happy appearing person to being a very frustrated, border on angry appearing, person. Just before resigning from the clinic, he briefly expressed to me that he could no longer work under those conditions, that wasn’t fair to his patients. Nothing has been the same since managed care and as far as I can see none of it is good.

Recently in the New York Times there have been several articles on the inability of antidepressants to address mild and moderate depression. Some of that information is provided in the post just prior to this one. I will be commenting on that for the next couple days. I will say, at this time, the issue of depression has become much too simplistic. Saying “depression” is like saying “cancer”. There are hundreds if not thousands of types, severities and causes. In general, every successful treatment starts with an accurate diagnosis. Spare no cost in getting an accurate diagnosis, it is your life you are wasting if you don’t.

Now here’s the challenge, if I’m treated for a disorder someone needs to get paid. If there is going to be a payment through some type of insurance, there must be an ICD code, specifically a selection from ICD-9 codes 290-319: mental disorders, in the case of a mental illness. This code does not contain sadness or grieving, consequently, anyone who is sad or grieving will be given a depression or anxiety code. We are now comparing apples to oranges in any study and getting poor inaccurate results.
Let’s take a look at this on a very basic level. I’m running antidepressant trial. Included are 6 individuals who are really sad, 10 individuals who are grieving, and 15 individuals who are truly clinically depressed. Just to complicate matters, five of the 15 depressed individuals actually had a bipolar disorder, which is usually first diagnosed as depression. In short form, the result of my trial will be useless. The result of a meta-analysis based on a number of such trials will be just as useless. You begin to see why we have made such poor progress with the treatment of depression in the past 50 years.