Depression is a major issue on a number of fronts. Clinically, depression is the most common presenting complaint in psychiatry and one of the most common presenting complaints in primary care medicine; it is a significant issue for most medical specialties, from cardiology and endocrinology to OB-GYN and dermatology. The socio-economic impact of depression is difficult to calculate and nearly impossible to overestimate. On a personal level, more often than not, depression is devastating to the afflicted individuals as well as to people close to them; all too frequently, it is lethal. Unquestionably, depression is relevant to happiness and its pursuit.
At the time of this writing, psychiatry has no objective diagnostic tools. There are no blood tests or imaging technologies that can support a psychiatric diagnosis. Adult psychiatric diagnoses are based on information provided by patients and the clinician’s subjective impression, compared against diagnosis-specific checklists. When the patient’s experience coincides with a minimum number of items on a checklist, the patient’s condition is said to “meet criteria” for that diagnosis.
The checklists for all recognized psychiatric disorders are presented in The Diagnostic and Statistical Manual of Mental Disorders (the DSM), published and periodically updated by the American Psychiatric Association. It is unquestionably primitive compared to today’s medical diagnostic standards, but it is better than not having a diagnostic system at all.
According to the most recent edition of the manual (DSM-5-TR, published in 2022) the diagnosis of major depression is based on a list of nine symptoms: Two “core” symptoms — depressed mood and anhedonia (defined as the “loss of interest and/or pleasure in all, or most, activities”), and seven “secondary” symptoms — sleep disturbance, appetite disturbance (typically manifested with a change in weight), poor concentration, fatigue, psychomotor (i.e., mental and/or physical) slowing or agitation, loss of self-esteem, and suicidal thoughts. A patient is diagnosed with major depression if they experience a total of at least five of the nine symptoms, at least one of which is a “core symptom”, for at least two weeks, representing a clear departure from the patient’s normal baseline state.
Focusing exclusively on a nine-symptom checklist cannot amount to even a cursory exploration of a person’s encounter with depression. To obtain more meaningful insight, I approach the complaint of “depression” as an overarching term covering three distinct states: ‘Grief,’ ‘despair,’ and ‘major depression’ (major depression, in my opinion, is a terrible clinical term, but I use it in the following as it is the current norm; a more precise term is sorely needed).
The main feature these three states share is an undesired negative mood. Because the negative mood is dominant, and because these states share other commonalities, accurately identifying which state is central to an individual’s presentation can be challenging. Occasionally, they overlap, which further complicates matters. Still, making this distinction is well worth the effort — it typically goes a long way toward gaining insight into the specific meaning of the very non-specific complaint of “depression.”
Until around the middle of the 20th century, psychiatry made these distinctions. Grief and despair were considered ‘reactive states’ — fundamentally normal reactions to difficult life circumstances that could occasionally become pathological. The term endogenous depression, later replaced by major depression, was reserved for a relatively rare and invariably serious medical illness.
Over time, the field has stopped making these distinctions. Both the general public and the mental health profession have come to consider fundamentally different depressive conditions as if they were a single problem — a “depression.” (Presently, in my experience, the majority of the patients diagnosed with major depression actually suffer from grief and/or despair.) Conflating the three states — grief, despair, and major depression — has grave consequences.
Let’s examine the three depressive states in some detail:
Grief
Sadness is a normal reaction to recognizing a loss of something of value (it can be an object, e.g., money, a function, e.g., the ability to walk, or a relationship, through a breakup or a death). The sadness elicited by loss is invariably unpleasant — it is an emotional pain. Grief is the suffering associated with the perceived pain of a loss; it is the meaning of a loss. Since loss is unavoidable, grief is inextricable from the human condition (a fact all too often overlooked by mental health professionals and nonprofessionals alike, perhaps more than ever in today’s discomfort-intolerant climate). (For a discussion of suffering as a meaning of pain, see the Pain, Suffering, and Misery chapter.)
Grief is experienced on an intensity continuum. Normally, the intensity is proportional to the magnitude of the loss that triggers it. Minimizing the magnitude of a loss is, therefore, a tempting way to reduce the intensity of the associated grief. Therein lies the lure of denial.
A brief period of denial in the immediate aftermath of a loss may be a normal, automatic psychological defense mechanism (more on this below). However, as an open-ended method of dealing with loss, it simply doesn’t work. Persistent denial usually increases the long-term hardship of coping with loss. Unacknowledged losses may linger subconsciously, potentially contributing to a nonspecific bad mood, thus compounding the negative impact of denial.
Grief is also a hidden aspect of regret and disappointment. For example, a person who turned down an offer to join a startup that subsequently became hugely successful would be expected to experience a negative emotional reaction in response to reminders of the wealth she could have had. Her response is likely to be labeled as regret. Deconstructing ‘regret’ reveals that one of its ingredients is grief — the response to the loss of something that could have been had, given a different past.
Similarly, grief is often a veiled part of disappointment. A young couple trying to conceive will inevitably experience disappointment with every failed attempt. A component of their disappointment is grief over the loss of the pregnancy and child they could have had.
Grief follows a recognizable progression. Normally, the first response to loss is denial — an automatic rejection of its reality. Denial is a psychological defense mechanism deployed subconsciously to protect the ‘Self’ from being overwhelmed by the emotions triggered by loss. This denial must subside for the grief process to progress; if it doesn’t, the grief reaction is considered pathological. The grieving process moves toward acceptance of the loss and resolution.
In my opinion, acceptance is not the final resolution point. After acceptance is established, the grieving process proceeds in one of two directions: the first resolves with inner peace. If inner peace is unattainable, the default alternative is surrender. If neither resolution can be reached, acceptance eventually becomes undermined, resulting in an ongoing inner conflict over the loss — the hallmark of pathological grief. Of the two resolutions, inner peace is clearly the preferable option. Both inner peace and surrender are preferable to entrapment in an unresolved inner conflict.
[Sidebar: The often-heard call to “never surrender” is infantile at best (it can be much worse — manipulative and nefarious). The mature, mindful approach aims to distinguish between situations that warrant struggle and those in which struggle would be futile. In the former, surrender is a mistake; in the latter, surrender, while inevitably bitter, is preferable to entering a doomed struggle.]
Resolution of grief inevitably takes time. Shortening the duration of normal grief is difficult (if not impossible), and prolonging it is easy. Hence, the primary goal of grief management is to refrain from making it any worse than it has to be. One sure-bet way to worsen the course of grief is to consider it an illness, i.e., as major depression. Treating grief as if it were major depression is guaranteed to interfere with the normal progression toward resolution and, at best, delay recovery from the loss. The consequences of misdiagnosing normal grief as a depressive disorder can be downright dreadful. Expecting relief from the hardship of grief in response to medical treatment is unrealistic — invariably, a setup for disappointment. The resulting worse mood (on the backdrop of the major depression misdiagnosis) justifies increasingly aggressive treatment, potentially starting a cycle of worsening mood symptoms and increasingly aggressive efforts to treat them — a nightmarish scenario that happens all too frequently.
Regardless of how unpleasant and difficult to bear it may be, grief is a normal response to loss. Moreover, the absence of grief in the face of a significant loss may be a symptom of a mental disorder or a harbinger of future emotional problems. Nonetheless, grief can be pathological — a potentially serious mental health problem requiring professional intervention.
Distinguishing normal grief from abnormal grief can be a clinical challenge. The distinction is generally made by assessing several factors, such as the intensity of the grief relative to the magnitude of the loss, the presence of persistent emotions and/or thoughts that are clearly superfluous to the loss (e.g., guilt, worthlessness, psychotic beliefs), and the pace of recovery (in comparison to the grieving person’s cultural norm). The assessment is inevitably subjective, but pathological grief is typically not subtle, making the right call fairly obvious.
Most cases of pathological grief stem from a psychological rather than a medical problem. Psychological problems require treatment with psychological means, typically psychotherapy. Psychological disorders do not improve in response to medical treatments (medications or other biological modalities). The medical treatment of psychological disorders is futile; at best, it is ineffective; at worst, it causes serious medical and psychological complications. Psychological disorders sometimes involve symptoms that may respond to medical treatment (e.g., insomnia), but both the recipient and provider of care must be clear that such treatment is symptomatic rather than curative. Otherwise, the negative impact is likely to outweigh the benefits.
Rarely, grief may trigger a frank psychiatric disorder (both new onset and recurrence can happen). It should be suspected when an individual’s reaction to a loss is radically different from the expected, normal course of grief in their culture. For example, increasing intensity of grief over time, the onset of psychotic symptoms, or persistent suicidal thoughts would be a cause for concern.
The progression from reactive grief to a frank psychiatric illness (rare as it is) is usually encountered in predisposed individuals — those with a personal or close family history of psychiatric illness (specifically major depression, bipolar illness, or a psychotic illness). The treatment in these cases aims to address the underlying psychiatric disorder rather than the grief. Lastly, grieving patients experiencing psychiatric symptoms but not meeting diagnostic criteria for any specific psychiatric disorder may be diagnosed with ‘persistent complex bereavement disorder’ (which is possibly a variant of major depression).
Grief and Mindfulness
Grieving mindfully (or ‘Right-Grieving’, as a specific case of the Buddhist concept of ‘Right-Suffering’) is rooted in maintaining calm and is supported by compassion, tolerance, and gratitude. I’ll explain: Maintaining ‘calm’ in the face of a significant loss is far from automatic. The instinctive response to a loss (or any pain) is to judge it as a negative or a ‘bad’ occurrence. The judgment, normal as it is, is the beginning of a reaction that undermines calm and is therefore incompatible with maintaining mindfulness. Mindful grieving then involves overcoming, or transcending, the innate tendency to judge our losses as ‘bad’, without denying the hurt they elicit.
Mindfulness practitioners aspire to cultivate the ability to relate to Reality without judgment. To a non-judgmental mind, a loss is neither positive nor negative, not a good thing or a bad thing — just a thing, an event that has taken place in one’s Reality. Without judgment, ‘Reality’ is perceived as flawless, i.e., as perfect (which is not to say it is ‘good’ or worthy of celebration; just without flaws). The functional importance of this stems from the fact that it is, automatically, easier to find acceptance of something when it is perceived as flawless; or, to put it in slightly different words — the perception of something as ‘perfect’ promotes its acceptance. Conversely, that which is perceived as ‘flawed’ tends to be automatically rejected; usually, it is considered ‘unacceptable’ until the flaws are corrected or, at least, until whoever is responsible for the flaws is identified. The need to accept a flawed reality usually triggers a struggle.
Maintaining calm in the face of a loss hinges on the ability to sustain a non-judgmental approach, which, in turn, requires secured access to the point of view from which Reality is perceived as ‘perfect,’ even if it is undesired and painful. The value of maintaining calm (which promotes acceptance) justifies the effort required to cultivate a nonjudgmental mind. The alternative, relating to painful experiences unquestioningly as ‘flawed’, promotes reactivity, ineffective struggle, and interference with establishing acceptance; it may be the norm, but it is far from the attainable optimal.
[Sidebar: ‘Perfect’ in the mindfulness context means without flaws at the present moment — not that Reality is ‘good’ or ‘desired.’ Once something exists, it cannot be improved upon in the present (though it may be improved in the future). This is not a qualitative judgment. Whether Reality is desired, pleasant, attractive, or painful is subjective and irrelevant to its perfection. The brain automatically judges painful experiences as ‘bad,’ equating pain with ‘flawed’ — as if something has gone wrong. However, pain is not objective evidence of a flaw in Reality; it is merely an undesired experience. Not getting what you want may hurt, but it is not evidence that anything is flawed. Reality often unfolds in an undesired manner, but it is not flawed.]
In addition to maintaining calm, the mindful approach to loss and grief also relies on compassion and tolerance (because both support acceptance).
Acceptance, by definition, is the centerpiece of compassion. Practices designed to cultivate compassion aim to strengthen the ability to identify and remove conditions one’s mind places on a person as a stipulation for their acceptance. Cultivating compassion, then, whether or not the practitioner is aware of it, is essentially cultivating acceptance. (Arguably, the importance of compassion stems from the fact that a compassionate mind has the ability to accept the Present exactly as it is.)
Acceptance of a problematic person is no different from acceptance of a difficult situation. Like muscle strength developed through weightlifting can be applied to tasks outside the gym, the strength of acceptance developed through cultivating compassion can be applied wherever it is needed, including in encounters with grief. In other words, a mind that possesses deep compassion has a strong “acceptance muscle” that can be put to use in the encounter with loss.
Tolerance — defined as the willingness and ability to observe discomfort or pain without reacting to it, is a core component of mindfulness; intolerance invites reactivity, which is contrarian to mindfulness. Tolerance is relevant to the encounter with grief because transcending the reflexive reaction to the pain of a loss depends on it. Reflexive behavior is effective in the face of survival threats, particularly when rapid reaction time is crucial. In all other circumstances, including the encounter with grief (which is not a survival threat, regardless of how much it hurts), reflexive behavior does not support the effective pursuit of happiness. Indeed, intolerance of the pain caused by a loss is guaranteed to interfere with progress toward acceptance and inner peace and thereby undermine the pursuit of happiness.
Mindful grieving is facilitated by understanding that not all pain serves the same function. Physical pain is a signal designed to direct attention to a problem in order to correct (or, at least, address) it. For example, stepping on a nail elicits pain, which directs attention to the injured foot and triggers corrective responses — applying pressure to stop bleeding, cleaning, dressing, and monitoring the wound. The sadness triggered by a loss doesn’t function to bring attention to a correctable problem. Functionally, it is the opposite — sadness, and the grief it triggers signal an irretrievable loss. The pain cannot be eliminated by fixing something; it can only be resolved through the process of grieving, which ultimately leads toward acceptance, inner peace, or surrender.
Consider, for example, a person waking up from an operation in which their leg was surgically amputated. Registering their loss, this person is likely to feel hurt (sans any physical pain, which, in our example, is completely blocked by analgesic medications). They experience sadness — the emotional pain of recognizing a major loss, and grief — the meaning of the sadness, that the loss is irreversible, i.e., that there is no corrective action to take, the amputated limb is permanently lost.
As a rule, evolution does not permit purposeless or nonsensical brain functions. Given that grief is a universal human trait, it must serve a purpose. Since the purpose of grief is not to bring attention to a problem in order to fix it, this raises the question: What is the purpose of grief? In part, the answer may be that the desire to avoid the unpleasantness of grief contributes to the motivation to act with caution, thereby reducing the likelihood of future losses. I think it is more than just that: Grief can elicit gratitude.
Grief can promote gratitude by drawing attention to the value of what was lost; if something has no value, its loss will not trigger grief. Moreover, normally, the intensity (i.e., the depth and duration) of grief is proportional to the magnitude of the loss that triggered it; the greater the lost value, the more intense the grief. One can only lose what one possesses. Hence, by directing attention to a value that was once possessed, grief can serve to bring it into conscious awareness. Awareness of the value once possessed invites its appreciation and, ultimately, gratitude for it. (For discussion of gratitude, see Cultivating Gratitude in the Practice section.) Like calm, compassion, and tolerance, gratitude also supports acceptance: Acceptance of a difficult circumstance is automatically made easier when something deserving of gratitude is identified in it. For example, when faced with the passing of a beloved person, it is common to automatically focus on the cessation of their suffering or on the notion that “they are in a better place.” Highlighting something to be grateful for in the loss makes it easier to accept.
Cultivating the ability to grieve with calm, compassion, tolerance, and gratitude is not easy; it requires considerable practice. Investing the required effort is worthwhile, not only because it makes it easier to accept our inevitable losses but also because it ultimately promotes inner peace and protects passion, which, as discussed earlier, are prerequisites for the effective pursuit of happiness.
Despair
Despair — also commonly and nebulously referred to as depression is a state of mind that emerges in response to entrapment. When repeated attempts to escape a trap fail, hope begins to erode. The loss of hope solidifies despair. Hence, despair can be defined as the state of mind that emerges when hope for freedom is lost (as a response to the loss of freedom and hope, despair can be considered a unique form of grief).
Animal studies clearly demonstrate that prolonged, inescapable entrapment leads to one of three predictable states: passivity (termed ‘learned-helplessness’), frenzied aggression (‘rage’), or alternation between the two in a mixed state (Seligman & Maier, 1967; Maier & Seligman, 2016). These three states represent different manifestations of despair in response to hopeless entrapment.
[Sidebar: 1. Since the 1960s, mainstream psychiatry has interpreted the ‘learned-helplessness’ state observed in these animal experiments as a model for human major depression. This interpretation has never been validated scientifically. More problematically, these experiments remain central to antidepressant development — a molecule that reduces study animals’ vulnerability to experimental “stress” is considered to act as an antidepressant. The systemic failure to distinguish between major depression and despair may explain, at least in part, the undeniable low efficacy of antidepressants and has likely misdirected decades of research and pharmaceutical development.
2. Chronic pain patients live in conditions similar to inescapable entrapment — exposed to persistent distress from which they cannot escape. The reported prevalence of major depression in chronic pain patients reaches 50-85% in some studies (Bair et al., 2003), which makes no sense for a biological illness. “Anger problems” and “agitated depression” are also remarkably common in this population. It is much more likely that most of these patients (like the study animals) are actually in despair, not major depression.]
The difference between despair and major depression is far from merely semantic. Both are depressive states, and thus, they share some superficial features, but they are inherently different conditions, each with its unique courses, symptoms, and psychological underpinnings. It stands to reason that they also differ in their underlying physiologic and biochemical underpinnings (which are yet to be delineated).
Failure to separate reactive despair from the biological illness of major depression explains striking statistical patterns: The prevalence of major depression in the general population is estimated at 10-15%. Among patients with serious chronic medical illnesses, it jumps to 30-50% — 2-5 times higher. Conversely, 65-85% (depending on the population studied and the breadth of conditions assessed) of patients diagnosed with major depression have at least one chronic medical illness (Wells et al., 1991). If these were independent conditions, such high co-occurrence would be statistically improbable. The much more likely explanation in my view is overdiagnosis of major depression resulting from failing to distinguish it from despair.
Astonishingly, the takeaway mainstream psychiatry draws from these statistics is that patients with chronic medical conditions should be “monitored closely for co-occurrence of major depression” — which is code for calling on clinicians to diagnose major depression more aggressively.
In addition to hindering our understanding of major depression and its treatment, ignorance of the differences between despair and major depression also obscures the significant role of despair in the human condition. Despair is much more common than major depression (a medical condition that, if diagnosed accurately, probably has a prevalence of around 1-3% in the general population). Conflating the two has essentially blocked understanding of the psychological and physiological mechanisms behind despair and obstructed the development of specific treatments for it.
Despair, as a naturally occurring state, is largely (if not exclusively) a human phenomenon — in nature, unlike in a laboratory, zoo, and other artificial conditions, trapped animals don’t survive long enough to develop despair. Humanity’s social structures, from the family unit to the state, and steadily growing scientific and technological prowess enable individuals trapped in “stressful” conditions to live life to its fullest expectancy, affording plenty of time to develop despair.
Entrapment in pain, physical and/or mental, is an extremely common phenomenon in the human condition. Chronic physical pain conditions create physically painful traps. Entrapment in mental pain is even more common — experienced by individuals with mental disorders (e.g., anxiety disorders, schizophrenia) and those experiencing persistent emotional pain unrelated to any disorder (e.g., loneliness, disappointment, regret, purposelessness). Yet despair is oddly overlooked by both the mental health professions and the culture at large.
Given modern psychiatry’s almost single-minded investment in major depression, a person in a state of despair seeking professional help is most likely to be misdiagnosed with major depression (or one of its close variants, such as agitated-depression and dysthymia; other common misdiagnoses of despair include adjustment disorders, personality disorders, and, in the all too common and worst case scenario, bipolar-depression).
Ignoring the distinction between despair and major depression is as consequential as conflating heartburn with cardiac chest pain — a diagnostic error with very serious clinical consequences.
[Sidebar: 1. The distinction between physical and mental pain is somewhat misleading. Pain signals originating outside the brain (e.g., the toes, stomach, or scalp) register as physical pains, and pain signals originating inside the brain (e.g., anxiety, guilt, disappointment) register as mental pains. In essence and function, both types of pain are the same phenomenon, regardless of their point of origin. Hence, patients who suffer from chronic mental pain are as susceptible to despair as patients with chronic physical pain.
2. The earliest example of inescapable mental pain is typically encountered before age 10, when we learn about death and dying. Discovering that we, and everyone we care about, are guaranteed to die is universally unpleasant. We quickly develop ways of dealing with the awareness of our mortality, but it remains a form of mental pain from which there is no escape — once learned, this uncomfortable knowledge persists and never becomes more attractive than it initially is. If we consider this as a trapping form of mental pain, it may contribute to our understanding of the high prevalence of despair, anger, and their mixed state in the human condition.]
More than three decades of practicing psychiatry left me with little doubt about the theoretical relevance and practical utility of correctly identifying despair. To illustrate this, consider the following, fairly typical, real case:
J. was a highly functioning adult with no personal or family history of psychiatric disorders and no history of problems with substance abuse. In his early 40s, he started experiencing diffuse joint pain, fatigue, and “brain fog.” These symptoms persisted, and after a couple of months, he brought it up with his primary care provider, who, after running some blood tests, referred him to a rheumatologist. The rheumatologist completed the workup and diagnosed J. with an autoimmune disorder. Under the rheumatologist’s care, J. started a series of medication trials. It was a slow process, testing J.’s patience (it usually takes a few months to complete each one of these trials; things were particularly trying for J. on a couple of occasions when his medical insurance company refused to cover a new medication until his doctor groveled long enough for their satisfaction).
After over a year of trying different medications, J. and his doctor found a treatment that was quite effective and had relatively few side effects. J. followed the treatment recommendations closely; his symptoms improved significantly, and his condition was considered stable.
J. was grateful for his doctor’s efforts, but remained frustrated with the overall situation: his symptoms improved but didn’t resolve completely, and he had to endure relatively mild but unpleasant side effects. He understood this was typical for his condition, but that didn’t help.
His residual symptoms were relatively mild, but unpredictably intensified to prevent normal functioning. Last-minute cancellations of plans with his wife or friends were particularly difficult. He hated disappointing people he cared about, which made him feel guilty and ashamed. He began avoiding plans altogether, which gradually led to a significant drop in his activity level.
Over the next few months, J.’s rheumatologist became increasingly concerned about his mental well-being; eventually, she recommended a consultation with a psychiatrist. She contacted me requesting “a psychiatric evaluation to rule out depression.” A couple of days later, J.’s wife called my office to schedule an initial appointment.
J. showed up on time for the appointment, accompanied by his wife. He stated he was seeing me for “depression” and acknowledged his mood had been “pretty lousy” most of the time “for months.” He denied suicidal thoughts. He endorsed lack of energy, poor concentration, occasional insomnia alternating with oversleeping, and weight gain. He became more easily frustrated and irritable. Clearly, he wasn’t enjoying life like he used to.
J. was open to trying an antidepressant medication. He stated that he had been ambivalent about taking “psych meds,” but having discussed it with his rheumatologist, he accepted that it could well be necessary.
His demeanor during the appointment was completely appropriate. He was somewhat distant and sometimes came across as a bit suspicious, but no more than I would have been in his place. His wife was pleasant, supportive, and concerned; she corroborated his account and had little additional information to share.
Clearly, J. endorsed more than enough symptoms to qualify for the diagnosis of major depression. My impression, however, was that he was in a state of moderate despair — the result of more than two years of feeling trapped by residual symptoms compounded by medication side-effects and the heartless bureaucracy of his insurance company. He had lost hope for a significant change for the better.
J. was reluctant to accept my opinion. He wasn’t receptive to the idea that his mental symptoms were a reaction to his circumstances, partly because he thought it suggested weakness of character and partly because he thought it would rule out an antidepressant trial — which, by then, he was more invested in than he realized.
We were not on the same page, and J. had to decide how to proceed. He had two options: get a second opinion from another psychiatrist (with my full support), or test my impression by doing a ‘diagnostic trial.’
Testing the validity of the despair hypothesis in such cases is relatively easy; all it takes is a short period of aggressive anti-pain treatment: If despair is a consequence of entrapment, liberation — the discovery of a way out of the trap — should change it significantly. In other words, if J.’s depressive state was indeed secondary to entrapment in chronic pain, effective anti-pain treatment should noticeably improve his depressive symptoms.
I have witnessed this many times: dramatic improvement of depressive symptoms in despair patients treated aggressively for their chronic pain. The sudden relief from chronic pain represents a way out of their trap. Finding even a small degree of freedom reignites hope, which negates despair, even without the patient’s conscious awareness of the underlying mechanism. (Chronic pain patients who also suffer from bona fide major depression, of course, welcome relief from pain, but they don’t respond with significant improvement in their depressive symptoms.)
[Sidebar: When patients with bona fide major depression respond to antidepressants, symptoms typically begin improving no sooner than four weeks after treatment starts. Rapid improvement (within days) has two likely explanations: placebo effect or misdiagnosis. The placebo response starts quickly (within a day or two) but is short-lived, rarely lasting two weeks. The second explanation is that the depressive symptoms are not from major depression.]
After reviewing the relevant pros and cons, and with his wife’s support, J. chose to proceed with the diagnostic trial. I prescribed methadone with instructions to adjust his dose to stop most of his pain while staying below a dose that caused sleepiness or sedation. We scheduled a follow-up in two weeks. The two-week interval is critical: too short for antidepressant pharmacologic effects to emerge, too long for placebo effects to be sustained.
When J. and his wife returned, as scheduled, J. was a changed man: He was cheerful, warm, and friendly. His delighted wife kept saying, “I got my husband back.” We were indeed on the same page moving forward — we agreed to taper the methadone over the following two weeks and scheduled regular meetings for psychotherapy and ongoing treatment considerations.
As expected, J.’s pain returned after the methadone was discontinued, but his rekindled hope persisted — finding a way out of his trap protected him from the recurrence of despair. He became more energized, increased his participation in physical therapy, and committed to a healthier diet and regular exercise. We started regular psychotherapy sessions, and he also began meditating. Over the following months, his physical pain decreased, his activity level increased, and his mood and outlook remained improved.
Our treatment plan included using methadone as needed, with inflexible parameters and a monthly maximum; he used much less of it than he had access to. As he said, the important thing was having access to the medication — it gave him real influence over his pain and contributed to his sense of freedom. He continued to do well. As he pointed out more than once, he wasn’t thrilled about having a chronic autoimmune disorder, but his experience wasn’t for naught. He considered the lessons he learned invaluable and broadly applicable. I hope and believe that what he learned contributed to his pursuit of happiness.
Interestingly, one of the latest FDA-approved treatments for major depression is Ketamine, which appears to work essentially instantaneously — a radical departure from traditional antidepressants’ 4-6 week delay (Krystal et al., 2024). Historically, Ketamine has been (and remains) used primarily for treating severe pain. This is unlikely to be coincidental. If the patients experiencing rapid improvement with Ketamine are actually suffering from despair rather than major depression, the instant relief makes perfect sense: pain relief represents liberation from their trap, reigniting hope and negating despair (Williams et al., 2018; Williams et al., 2019). Psychiatry celebrates Ketamine as a breakthrough in depression treatment. It may instead be further evidence of the field’s systemic failure to distinguish despair from major depression.
Clinical experience raises an important question: Clearly, many patients (as well as animals in the stress experiments) who suffered from despair benefited from the use of an antidepressant. Granted, the rate of response to antidepressants is far from 100%, but any significant superiority of medical treatment over placebo suggests that something is working. The question then is the following: If that which is being treated is despair (i.e., a reaction to entrapment and hopelessness) rather than a medical illness (i.e., major depression), why does it improve in response to medical treatment at all?
The answer, in my opinion, has to do with the analgesic (pain-reducing) effect of antidepressants: Most antidepressants have a well-established anti-pain effect independent of their presumed mood-elevating effect (indeed, antidepressants are a first-line treatment for chronic physical pain; several are approved by the FDA for use as anti-pain medications, even in the absence of any depressive symptoms). The point here is that, at least some of the time (perhaps much of the time), the apparent mood-elevating effect of antidepressants is likely to be a consequence of their pain-reducing effect.
Antidepressants can have a comparable pain-reducing effect to opioids (like methadone in J.’s case), but much slower to take hold — it usually takes a few weeks of treatment before the initial effect is noticed. Once it does, however, it represents a way out of the patient’s perceived entrapment; even if it is not consciously appreciated, it rekindles hope and thus negates despair.
Antidepressants also have a pronounced anti-anxiety effect (many have FDA approval for anxiety disorders, and most of the rest are frequently used off-label to treat anxiety). This is highly relevant because anxiety is a form of pain, and entrapment in it predictably leads to despair. Over the years, I have seen countless patients who presented complaining of ‘depression’ — many already diagnosed with major depression — who were actually in despair secondary to the chronic pain of untreated anxiety. Most were prescribed an antidepressant, and many improved, but not because the antidepressant treated major depression; it treated their anxiety, which relieved the pain fueling their despair. Since the improvement followed a course of treatment with a medication known as an antidepressant, both patient and provider automatically considered it evidence of the validity of the major depression diagnosis. The reality — that the problem was despair, not major depression, and that the mood improvement was secondary to relief from the pain of anxiety — remained obscured. Urg.
(For detailed discussions of anxiety, see the Anxiety chapters in the Theory and Practice sections.)
Anxiety can be relieved acutely, sometimes dramatically, in response to treatment with a class of medications known as benzodiazepines (e.g., Valium, Xanax, Klonopin). As with opioids for physical pain, the relief is rapid — often noticeable after a single dose. Hence, these medications can similarly be used diagnostically: patients in despair secondary to anxiety typically show significant improvement in their depressive symptoms within days of effective anti-anxiety treatment with a benzodiazepine, just as J.’s depressive symptoms resolved within days of effective anti-pain treatment. (As with opioids, the long-term use of benzodiazepines is controversial and warrants careful consideration of the significant potential for complications.)
So far, anxiety is the only mental pain that can be acutely relieved with a medication; therefore, there is no ‘diagnostic trial’ to confirm or reject the despair hypothesis for patients struggling with other mental pains (e.g., self-doubt, guilt, regret, shame). Nonetheless, their despair follows the same course: it resolves when hope for liberation is rekindled. In my experience, psychotherapy is the primary (if not the only) treatment modality likely to help. Typically, it is effective when the patient discovers that they can influence their own mental process — that they are not as trapped as they believed.
Normal and Pathologic Despair
Despair is normal in the face of entrapment with no hope for escape. However, it is not inevitable, even in the face of extreme hardship (as illustrated by the lives of Nelson Mandela, Stephen Hawking, and the Dalai Lama, to name a few examples). The ability to transcend despair should not be considered superhuman. Countless anonymous, ordinary people throughout human history have faced tremendous adversity without succumbing to despair; it requires a high level of psychological maturity and/or unshakeable spiritual balance, but not superhuman abilities.
Despair, however, can be pathological, resulting from either a biological or psychological dysfunction. Biological despair is presumably uncommon and very difficult to distinguish from extreme major depression (I suspect there is a significant overlap between these two states). It probably manifests a breakdown of the brain’s hope-generating apparatus (which is yet to be delineated).
Despair secondary to a psychological dysfunction — reactive pathological despair — is presumably much more common. The psychological backdrop ranges in severity from immaturity to adjustment and personality disorders. The common thread is the patients’ stubborn attachment to an unrealistic point of view from which they appear, to themselves, trapped with no hope of escape — contrary to an objective analysis of their circumstances. For example, the conviction that one is inherently unlovable and thus doomed to a life of loneliness, or inherently not good enough and thus doomed to fail. Such convictions readily become self-fulfilling prophecies, which reinforce the hopeless attitude and solidify despair.
Despair can also emerge from an intense discomfort with uncertainty (a key feature of high anxiety states). Uncertainty is a prerequisite for hope — where there is uncertainty, there is hope and, conversely, where there is certainty, there is no hope. (For a detailed discussion, see the Hope chapter in the Theory section.) The illusion of certainty is dangerous — it is seductive, largely because it has an anxiety-reducing effect (even if the predicted outcome is negative, e.g., ‘I know I’m not going to get the promotion; I am always looked over’), yet it is a veiled setup for hopelessness and, ultimately, despair. Anxiety disorders, then, can contribute to despair in two ways: one is through entrapment in chronic mental pain, and the other is by negating hope as a result of discomfort with uncertainty.
Reactive despair can be addressed with psychological means, i.e., psychotherapy and/or a spiritual practice, both of which are supported by mindfulness. The mindfulness-based approach to despair is grounded in the same concepts discussed in the context of grief above — specifically, tolerance and compassion.
The relevance of tolerance to the management of despair stems from the critical difference between reactivity and deliberate activity. Reactive or reflexive behavior, by definition, circumvents thoughtful assessment of circumstances. In the pursuit of happiness, such behavior is, at best, ineffective; often, it makes matters worse. Persistent futility augments the sense of entrapment, undermines hope, and thus invites despair.
Hence, from a mindfulness perspective, it is preferable to refrain from any action until the right-action becomes clear — which requires tolerance. Tolerance enables resisting the impulse to react and, instead, to search for and discover the right action. Right actions, by definition, increase one’s influence over their circumstances (which is what makes them ‘right’). The degree to which one can influence their position is the degree of freedom they possess — and the degree of their immunity from despair.
Compassion negates despair by protecting mental freedom.
The experience of freedom (and of entrapment) is inseparable from the awareness of time. Both freedom and entrapment have meaning only when they are bounded by a specific length of time (it is no coincidence that a prison sentence is referred to as ‘doing time’ or ‘serving time’). A wrong attitude toward time (and any one of its components — the past, present, and future) typically results in a sense of being stuck, or trapped, in it, which is synonymous with experiencing a loss of freedom.
Conversely, the right attitude toward time offers protection from getting stuck, or trapped, in it. The right attitude toward time is encapsulated in the following triad: forgiveness of the past, acceptance of the present, and hope for the future. Forgiveness negates entrapment in past trauma. Acceptance negates entrapment in a futile struggle with the reality of the present. Hope negates entrapment in an imagined future.
Compassion is, by definition, based on acceptance. Acceptance of the present becomes meaningless unless it is supported by forgiveness of the past and hope for the future (without hope, it becomes surrender). Hence, cultivating compassion is cultivating the right attitude toward time, with or without the conscious realization of it.
Major Depression
Major depression is a serious medical illness. In my view, it is a relatively rare condition — with an actual prevalence closer to pre-DSM-III estimates, a small fraction of the mainstream figures of 10-15% that have become standard since the broadening of diagnostic criteria in 1980 (Horwitz & Wakefield, 2007).
[Sidebar: Research suggests that the overdiagnosis of major depression is widespread; a large-scale study found that only 38% of patients with clinician-identified major depression actually met the diagnostic criteria (Mojtabai, 2013).]
Unfortunately, the term has come to be applied broadly to any condition involving sadness, regardless of whether it has anything to do with the actual disorder. In my clinical experience, only a small fraction of the patients I have seen who were previously diagnosed with major depression actually suffered from it. The majority suffered from grief, despair, adjustment disorders, or personality disorders; many don’t suffer from any pathology at all — they struggle with harsh life circumstances and ultimately with grief and despair.
In part, the problem stems from the fact that major depression is a lousy name for an illness. First, the word ‘depression’ lacks specificity — it describes a very broad range of human experiences, from a trivial emotional reaction (‘Jill was depressed when the Lakers lost the series’), to a perfectly normal but unpleasant emotional state (‘We were all depressed when dad died’), to a psychological disorder (‘adjustment disorder with depressed mood’), to a serious medical condition associated with disturbingly high morbidity and mortality rates — the bona fide diagnosis of major depression.
Second, the qualifier ‘major’ — meant to distinguish the illness from other ‘depressions’ — only adds to the murkiness. It implies the existence of a ‘minor depression,’ a term that was unfortunately absorbed into professional terminology as a clinical diagnosis. As a diagnosis, minor depression is even more poorly defined than major depression; thankfully, it is rarely used in practice.
Third, and most critically — the ‘thing’ that is depressed in major depression is obviously the patient’s mood. The term implies that the condition is fundamentally a mood disorder hallmarked by sadness — an idea so ingrained in professional and general thinking that stating it seems redundant. However, this broadly accepted notion has never been scientifically proven or even meaningfully tested. It is largely arbitrary, based on assumptions rather than evidence, and driven by subjective interpretation of patients’ appearances, who may or may not actually suffer from the disorder. It is entirely possible that sadness is not a central feature of major depression at all.
In my opinion, bona fide major depression is fundamentally a disorder of caring or passion rather than a disorder of sadness or mood.
As discussed earlier, caring and passion are synonymous — both refer to the intensity of one’s emotional experience, manifesting the strength of attraction toward what is desired and repulsion from what is threatening. An impairment of this capacity amounts to loss of the emotional force that normally propels a person toward or away from the things that matter to them, resulting in a form of paralysis. The consequences of a malfunction of the capacity to care are severe, yet they are typically veiled and easily overlooked.
As I see it, the loss of the ability to care is the main issue in bona fide major depression. Sadness is, of course, a symptom in some cases of major depression, but it is a distant, secondary feature, not a central characteristic of the disorder (indeed, sadness is not a required symptom for the formal diagnosis of major depression, as discussed below).
The misplaced focus on sadness as a central feature of major depression is a costly mistake. It contributes to the blurring of the distinction between major depression and the other states in which sadness is central (e.g., grief and despair). It is a major factor in the meteoric rise in the prevalence of major depression seen over the last few decades (Aragonès et al., 2006). It impedes research, derails clinical efforts, and legitimizes the mislabeling of a broad range of normal human experiences as a disease.
The formal diagnostic approach to major depression (as outlined in all DSM editions since 1980) is actually consistent with this view. The DSM criteria require the presence of only one of the two core symptoms: either a profoundly depressed mood or anhedonia — not necessarily both. Anhedonia is defined as the loss of interest and/or pleasure in all, or most, activities — essentially, an impaired ability to care or experience passion. The DSM gives anhedonia the same diagnostic weight it gives depressed mood — in other words, one can suffer from major depression without experiencing a depressed mood.
Over more than 30 years of practicing psychiatry, I have seen countless patients whose primary complaint was depressed mood or just depression. The vast majority suffered from grief and/or despair. Invariably, they struggled with sadness and, often, with other negative emotions. But, typically, their capacity to care was intact, which actually amplified their suffering. On the other hand, I don’t believe I’ve seen a patient with bona fide major depression whose ability to care, or experience passion, was intact. The comparatively rare patients who suffered from bona fide major depression were not particularly sad; usually, they were impassive, describing their mood as bland or dreary. Their primary problem was a loss of the ability to experience any emotion with normal intensity.
Patients with major depression always suffer from anhedonia. They tend to describe it as an odd, overpowering apathy — a strange, forced detachment from the facets of life that, intellectually, they know are most important to them.
One of the most heartbreaking illustrations of the inability to care, as the centerpiece of major depression, is postpartum depression (PPD). Postpartum depression usually starts within a few days following delivery. Women with PPD experience the typical symptoms of major depression compounded by a sense of colossal failure and intense self-loathing that result from the pathological breakdown of their ability to care about their newborn child. The agony of a new mother who, as a result of a medical disorder, is unable to experience normal caring for her child cannot be captured in words.
It is difficult to overemphasize the importance of the normal capacity to care (nonetheless, I’ll give it a shot). Caring manifests with attraction or repulsion and, as such, it is a mobilizing force. In other words, it is a source of motivation. Thus, loss of caring explains the lack of motivation that is an ever-present feature in major depression.
Caring plays a role in a host of key brain functions, which fail when the capacity to care is impaired. Many of the symptoms of major depression can be explained as consequences of these failures. For example, impaired concentration — a ubiquitous symptom of major depression — is downstream from impairment in caring. Normally, things we care about are interesting, and we automatically pay attention to what interests us. Loss of caring manifests as loss of interest, which undermines attention, ultimately presenting as decreased concentration. Moreover, since functioning effectively in most roles (interpersonal, academic, professional) hinges on the ability to pay attention, loss of caring capacity explains the DSM diagnostic requirement of impairment in social, occupational, or other important areas of functioning.
Loss of caring about the Self explains some of the common characteristics of the disorder, from neglect of personal hygiene to increased propensity for accidents. In extreme cases, it may manifest as a loss of interest in sustenance, which can become life-threatening.
Loss of caring about one’s future contributes to patients’ lack of motivation and, equally important, hopelessness. Extreme hopelessness can manifest with repulsion from every imaginable future. When the future becomes repulsive, dying becomes attractive, which, at least partially, explains the preoccupation with death and the resulting risk of suicide, the most disturbing symptom of major depression.
Caring is also critical to the feeling of connectedness. The cascade that begins with a lack of caring (→ lack of interest → lack of attention → poor concentration) results in exclusion of data from conscious awareness, because information the brain deems not important enough to receive attention tends to be automatically excluded from consciousness. Obviously, parts of reality that don’t show up in consciousness are not available for the mind to connect with. Consistently, patients with bona fide major depression typically report feeling painfully disconnected from the world around them. With progressing severity of the disorder, the disconnectedness can intensify and eventually become a sense of total isolation. The fear of isolation is a primal fear (solitary confinement is the most severe form of punishment, even in the harshest prisons). This oppressive sense of isolation makes major depression a uniquely horrifying medical disorder.
Anhedonia — the impaired ability to care — is a much more sensible explanation than sadness, or any other kind of bad mood, for many of the signs and symptoms of major depression. Sadness can be very unpleasant, even extremely difficult to endure, but it does not necessarily impair functioning, and, in and of itself, it lacks the nightmarish quality of major depression.
Clinical Considerations in Major Depression
Unlike grief and despair, which may be either normal or pathological, major depression is always a pathology: major depression is a serious illness affecting the brain.
While theories abound, the actual cause(s) of major depression are presently unknown. The consensus is that it is a biological, rather than a psychological, condition. This notion is supported by numerous studies that indicate a role for inheritable or genetic factors in the disease. For example, family studies indicate that first-degree relatives of patients have a two-to-threefold increased lifetime risk of developing the disorder compared to the general population, and twin studies suggest that the disorder has a heritability rate of 40-50% (Sullivan, Neale, & Kendler, 2000; Flint & Kendler, 2014). Additional evidence of the biological underpinnings of major depression is provided by a large body of research and vast clinical experience indicating that (accurately diagnosed) major depression responds to several biological treatment modalities.
The most commonly used biological treatment of major depression is pharmacological, i.e., antidepressant medications. Other biological treatment modalities with demonstrable efficacy and FDA approval for clinical use include Transcranial Magnetic Stimulation (TMS) and electroconvulsive therapy (ECT). The role of non-biological treatments (i.e., psychotherapy, exercise, meditation) in the treatment of bona fide major depression is, at best, secondary (more on this below).
The clinical characteristics of bona fide major depression are well established: It is an acute, episodic, disabling, and recurring illness. Permit me to relucidate:
- The acuity of major depression means that it has a rapid onset. The period between patients’ functioning at their normal level and the time they experience full-blown symptoms is measured in days or weeks, not months or years. The DSM reflects this by requiring as brief as a two-week period of persistent symptoms, representing a sharp departure from the patient’s baseline.
- The episodic nature of the condition means that patients do not experience symptoms before an episode begins and after it resolves, and most patients return to their pre-illness state and level of functioning. More often than not, consistent with the biological underpinnings of the disorder, episodes present out of the blue rather than as a response to an identifiable loss or stress (though they can be precipitated by stressful events). Episodes of major depression are generally self-limiting — most cases resolve with or without treatment. Nonetheless, treatment is valuable because it can reduce the severity of symptoms and shorten the duration of an episode. Moreover, given that suicidality is one of the symptoms of the disease, effective treatment may reduce the risk of premature deaths.
- Major depression is a disabling condition; it is not subtle. As noted earlier, according to the DSM, impairment in social, occupational, or other important areas of functioning is a diagnostic requirement. Indeed, episodes of bona fide major depression invariably involve significant functional impairment, if not complete disability.
- Because it is a recurring disorder, most patients experience more than a single episode in their lifetime. An episode of major depression is the primary risk factor for encountering future episodes. The average duration of an acute episode and the period between episodes are matters of some controversy, hampered primarily by the high rate of misdiagnosis. As a rule of thumb, the average duration of an episode is 6-9 months, and the average duration of the period between episodes is around five years. The duration of an episode can be shortened with treatment; the inter-episodic phase may be prolonged in some cases with the use of prophylactic treatment.
Regrettably, the disorder’s well-recognized characteristics are often overlooked (understandably by laypersons, inexcusably by researchers and clinicians). For example, the diagnosis of major depression is frequently made with disregard to both the acuity and the severity that define the condition. The diagnosis is routinely given to patients who clearly suffer from insidious and chronic mental disorders (as opposed to acute and episodic). Patients are routinely diagnosed with major depression despite having struggled with the same symptoms for years (often beginning in adolescence or earlier). Moreover, it is not uncommon for the diagnosis to be made without an observable, or even reported, change in the patient’s level of functioning. Doubtlessly, these patients suffer from something, but major depression it is not.
Psychiatry recognizes chronic depressive disorders, including chronic major depression and dysthymia (a depressive disorder persisting for a minimum of two years with fewer or less severe symptoms than full-blown major depression). Both are quite rare and diagnostically elusive — very difficult to distinguish from personality disorders, substance abuse disorders, persistent grief and/or despair, and a general dissatisfaction that stems from an ineffective pursuit of happiness. Consequently, they are likely overdiagnosed.
Complicating matters further, over the last several decades, psychiatry has become increasingly enamored with a condition referred to as Treatment-Resistant Depression (TRD). The definition of TRD, and its distinction from chronic major depression, are loosely established at best. According to many experts (both in academia and in the pharmaceutical industry), major depression should be considered treatment-resistant after two “adequate” medication trials prove ineffective (McIntyre et al., 2023; Howes et al., 2022).
In my opinion, this broadly used definition of TRD contradicts reasoning and common sense: the most likely explanation for a lack of response to two antidepressant trials (consistent with Occam’s razor) is that the condition being treated is not major depression. Declaring it a treatment-resistant major depression after two (or any number of) failed medication trials seems, at best, arrogantly out of touch with the reality of the field’s diagnostic and therapeutic limitations (oh, the irony of psychiatrists operating out of touch with reality).
Major Depression from a Psychological Perspective
The fact that major depression is a biological disorder does not mean that psychological considerations are irrelevant. On the contrary — psychological issues are relevant to all stages of the illness, before, during, and following an acute episode.
Let’s first examine the psychological factors that can contribute to major depression:
Situational (i.e., environmental) factors play a significant role in many medical disorders, especially for genetically predisposed individuals. For example, dietary habits and a sedentary lifestyle clearly impact the onset and course of conditions such as type II diabetes and coronary artery disease. In the case of major depression, situations in which caring leads to suffering represent a psychological environment that can contribute to the precipitation of a depressive episode, especially for individuals biologically predisposed to developing the disease.
As a rule in the human condition, caring is linked with suffering: The more one cares about something, the more they stand to suffer when things go wrong. Conversely, not caring offers a degree of immunity from suffering when things go wrong.
[Sidebar: The etymology confirms this link: ‘passion,’ synonymous with caring, derives from the Latin ‘passiō’ — suffering. The passion of Christ is the suffering of Christ. (The overlap of caring and passion is discussed in detail in the Caring, Matterness, and Significance chapter and the Happiness chapter).]
Actively minimizing caring is easy — it is accomplished by assigning it a negative value. This is the dynamic behind the peculiarly common depiction of caring as a childish, naive, or feminine (and therefore, weak) trait, and the similarly peculiar opposite, when not-caring is valued as evidence of growing-up, getting-real, or manning-up.
The link between caring and suffering is a potential source of a psychological problem. When reducing one’s caring is rewarded by lessening the pain, it is likely to be repeated; with enough repetition, avoidance of caring can become second nature. A systematic retraction of caring can amount to conditioned anhedonia. In individuals biologically predisposed to major depression, it may play a role in triggering episodes of the illness (it may mimic major depression in individuals who are not predisposed to the disorder).
Imagine a college freshman who just learned she failed the final exam in a core course. Failing an important exam hurts, and she is likely to associate the intensity of her pain with the level of her caring — the more she cares, the more it hurts. Therefore, she may try to reduce her caring as a way to reduce her pain, repeating to herself that she doesn’t care or shouldn’t care about the exam, the class, or even her education in general. This line of thinking is very likely to be encouraged by well-meaning friends and relatives who tell her she cares too much or that she shouldn’t care so much.
If she happens to be biologically predisposed to major depression, her perception of normal caring as a liability, followed by repeated attempts to extract it from her mental process, may contribute to the conditions that lead to her first acute episode. (If she is not predisposed, the same experience may trigger grief or despair — either within normal boundaries or pathological. If she seeks professional help, she is likely to be misdiagnosed with major depression.)
Let’s move on to examine the psychological consequences of major depression. An encounter with a serious medical condition — such as a heart attack, cancer, or major depression — often elicits a significant psychological reaction commonly manifested with loss of self-confidence, a heightened sense of vulnerability, anxiety, anger, and behavioral avoidance (particularly of situations regarded, consciously or not, as risk factors for the initial illness).
It is important to identify the psychological reaction to a serious illness for what it is and, when indicated, treat it accordingly, i.e., with psychotherapy.
When the medical illness is major depression, it is particularly challenging to separate the primary (medical) symptoms from the secondary (psychological) symptoms. Since the psychological symptoms tend to persist long after the resolution of the primary illness, it is easy to misconstrue the reaction to the illness as evidence of treatment-resistant major depression.
Psychological symptoms do not respond to medical treatment. The lack of response is readily interpreted as confirmation of treatment-resistant major depression, sometimes triggering a sequence of increasingly aggressive treatment trials. These trials often involve significant adverse effects. In the worst case scenario, the distinction between symptoms and side effects is lost, which can lead to a tragic outcome: Over the years I have seen more than a few patients disabled by what they considered symptoms of a depressive disorder (most commonly lethargy, oversleeping, poor concentration, and loss of libido) only to discover, following the discontinuation of treatment, that their residual, “treatment-resistant symptoms” were actually side effects of an unnecessary treatment.
The psychological consequences of major depression manifest at the relationship level as well. Major depression is associated with an increased rate of divorce, not surprising given the illness’s core symptoms: it is easy to misinterpret the reduced caring, loss of interest, and disconnectedness as a relationship commentary. These symptoms can be confusing to both the patient and their partner and have the potential to damage their relationship. Conversely, recognizing that diminished capacity for caring and its various consequences are symptoms of a medical disorder can go a long way toward protecting patients’ relationships. Couples therapy, therefore, definitely has a role in the comprehensive treatment of major depression.
Mindfulness and Major Depression
The mindful approach to major depression, in principle, is not different from the mindful approach to any serious illness. Major depression, however, presents unique challenges to operating mindfully because it is a brain disorder.
Problems that impact the brain directly (i.e., all psychiatric and many neurological disorders) represent a unique threat to the maintenance of one’s mindfulness baseline. Brain disorders threaten the quality of the brain’s ultimate product — the choice. This is critical because the choice is the point of interface between a consciousness and the reality in which it operates; it is the only instrument with which we can influence our environment. (For a detailed discussion of this point, see the Choice Making chapter.)
As with grief and despair, compassion is the centerpiece of the mindful approach to major depression, because cultivating it automatically strengthens hope, tolerance, acceptance, gratitude, and calm.
In addition, the practice of mindfulness protects the capacity to care. Caring mindfully is fundamentally safer than caring instinctively because it maintains a distinction between how much one cares about something and how much that thing actually matters. Without this distinction, caring and matterness are automatically equated — the more something hurts, the more important it seems — which makes caring a perpetual threat.
To revisit our imaginary student: the moment she learns she failed the exam, her caring surges — she has a strong emotional response. But how much failing the exam actually matters is completely unknowable at that moment: it may turn out to be forgotten by the end of the next term, or it may change the course of her life. Caring mindfully means recognizing that these are not the same thing. (The distinction between caring and matterness is discussed in detail in the Caring, Matterness, and Significance chapter.)
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[P.S.: The second citation above (Dr. M. Angell) refers to an essay by the former Editor-in-Chief of the New England Journal of Medicine. The essay concludes with: “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.” In addition, it suggests that while conflicts of interest pervade all of medicine, “they reach their most florid form” in psychiatry. I think it is impressive enough to justify breaking away from the regular Reference format.]