The connection is sometimes illusory
It is a commonplace that when bad things happen, people feel bad. Feeling depressed is just one of the many emotional states that constitute a reaction to the constantly varying conditions of our lives. We are at any one time worried, or gleeful, or angry– or feeling some less specific emotion—in response to something said to us, or done to us, or as simply a product of the happenstance of the day’s events. If someone were to ask us, “Why are you frightened—or angry—or aggrieved?” we would most of the time be able to give an explicit answer. “I am depressed because my friend snubbed me—or because I failed at an important task—or because I have been turned down for a job—or because I have been abandoned by the person I love.”
In an ordinary day there are probably countless reasons for feeling a little sad, or sad for a little while—just as we have reasons to laugh now and then, or feel angry (a little) off and on all the throughout the day. The disappointments that make someone feel sad are myriad; but those that cause us to become profoundly sad usually represent some sort of serious loss. Examples of such serious losses are the loss of a valuable job, the death of someone important, the development of a serious illness, and the abandonment by a lover—or, simply, the loss of self-esteem that comes from being admonished by someone important. This sort of depression can be profound. There are those who have become suicidal in the wake of a broken relationship or marriage.
It is natural, therefore, for someone to ask “Why are you feeling so sad?” if you appear to be depressed. And in the ordinary course of events, it is possible to give an accurate answer. “I feel this way because thisparticular thing happened to me.” Rarely, people catch themselves feeling sad and not immediately remembering exactly why —and, then, a few minutes later on, remembering. People have the experience sometimes of feeling sad “for no reason,” and then remembering a small thing that happened which was then recognizably the cause. It might have been only a sad story told about an acquaintance, or even a sad movie. Psychological events are presumed to have psychological causes. If the cause is not apparent, it is assumed anyway that there is a hidden reason for feeling that way, buried, perhaps, in our unconscious mind. Even happy events, such as a wedding, can be reasonably construed to cause a sad feeling because there is implicit in such a union the relative loss for others of a previous closeness. Parents may cry since a wedding is not usually experienced as “gaining a son;” it is more like “losing a daughter.”
The sort of depression described above, even when it is profound, does not respond to drugs. It gets better when the loss that has been experienced is made up in some way. It is like an exaggerated form of grief. People get better with time. Psychotherapy is helpful in providing support and guidance. But someone jilted by a lover will recover finally—completely– only when someone else has taken that other person’s place.
And then there is the “major depression” that is treated with drugs. This is a condition that tends to run in families and that usually starts in late adolescence, or in the twenties, although it can start at any age. It is relapsing and remitting; that is, untreated it tends to disappear after a year and then reappear at intervals throughout life. It can become chronic. It is marked by the vegetative symptoms I have discussed in previous blog posts: a characteristic disturbance of sleep, a loss of appetite, a loss of interest in sex, and a diurnal variation in mood—at its worst in the morning and somewhat better later on in the day. It is an illness. Still, it is natural to ask what was the psychological event that may have precipitated such a condition.
I was trained in the psychoanalytic tradition, so in addition to the common sense reasons I mention above for looking for underlying psychological causes, I was trained to think there was always an unconscious reason for feeling whatever we feel. Besides, I was influenced by the movies where with the help of dreams, perhaps, it was always possible to find the deep-down cause of the patient’s distress, thereby freeing him from his illness and allowing him to live cheerily from then on.
I became preoccupied during my residency with a particular woman who became seriously depressed, relieved only by electric shock treatments, at intervals of one to two months. I knew her for a period of approximately two years. Even granted that she had an organic illness that was precipitating these attacks, I thought it must be possible, at least, to figure out why they came at the particular times that they did come. One day she was fine. A few days later, she was so depressed as to constitute a suicidal risk. Why?
I considered changes in her family life, casual remarks made to her, “happy events” such as a child going off to college, peripheral events, such as the books she was reading. I tried to make a connection with her menstrual periods, illnesses—illnesses in her family! Watching her life from very up close, I was unable, ever, to predict when she was going to get sick. Neither could she venture a guess about what was bothering her deep down—if there was a deep down and if there was anything down there bothering her.
Plainly, there had to be some reason for her feeling one way one day, and not the next. Even if there was a cause that was not psychological, there had to be some cause. But I could not figure out what it was.
Over the years I have had many patients who did have theories about why they had become depressed:
“My boss has been very rude to me.”
“My mother-in-law insulted me in front of everybody.”
“My husband went on this long trip, leaving me alone.”
But, as I pointed out to my patients one after the other:
“Your boss is always rude to you and was even worse last year; and you didn’t get depressed then.”
“Your mother-in law has been insulting you since the day you were married; and you didn’t get depressed then.”
“Your husband goes on long business trips three times a year; but this was the first time you got depressed.”
The nature of life is that there is always something going wrong, and always something a depressed person can point to if that person searches for something to explain being depressed. And patients do search for something. They want there to be meaning in the way they feel. Even when I point out that the reasons they give themselves for being depressed are untenable; they are not convinced.
I was called by the administrator of a nursing home where I worked at the time to see a 70 year old woman who seemed to have become depressed. And she was depressed. It seemed to take an effort just for her to talk. I asked her why she was feeling so sad.
“I don’t want to tell you,” she said.
“Well, maybe you better. Otherwise I might not be able to help you.”
After a pause. “Well…when I was seventeen…I let a boy touch me in a place where I shouldn’t have.”
“That’s been bothering you all this time?”
“No. But I’ve been thinking a lot about it recently.”
This is what really happened: she did not get depressed because she had been indiscreet during her adolescence; she got depressed first; and then searched through her experiences for something to explain her depression.
Another man whom I have seen through two different depressive episodes always comes to me complaining of an incident in childhood that struck me as so trivial that I don’t remember it now. Three weeks later, when the anti-depressant drugs kicked in, he no longer thought or spoke about that incident. A few years later, when he got depressed again, he once again began mulling over this childhood event, and then three weeks later forgot it all over again! The incident itself was not what made him depressed years later; it was a bad thought that came to him because of his depression.
I saw a 60 year old lawyer who had become depressed for the first time. He reported in convincing detail the reasons for his depression: his office had recently burned down with the result that he could not afford to keep his staff, and his practice was threatened by the recent loss of a valued employee. And there were also family matters. He felt so hopeless that he had made a suicide attempt and was, for that reason, hospitalized. A month later he was feeling fine. I asked him about all the very real problems that had been bothering him.
“Well, I didn’t make any of that up; but I’m taking care of them. I found a new office, and I’m interviewing new employees…”
His psychological circumstances had not changed; his attitude toward them had changed. If he had not started to get depressed, these difficulties would not have affected him any more than many similar problems had earlier in his life.
Another 70 year old woman came to my attention directly after the death of her second husband. I was initially inclined to think she was suffering a grief reaction; but when she began developing the vegetative symptoms of a clinical depression, I put her on medication. She did well, and, a number of months later visited Florida where she met “Mr. Right.” When the two of them returned, I took her slowly off her medication, and she became depressed all over again. And she began to miss her second husband! She had not mentioned him to me in months.
Patients will always look for reasons for their having become severely depressed. And, as a therapist, so do I. But this is what I have come to believe: Recurrent Major Depressions are triggered at intervals for no discoverable reason. They seem to start more commonly during certain seasons of the year; and they may develop along with hypothyroidism or certain infectious diseases, such as infectious mononucleosis—but only rarely. Beyond that, I have not the faintest idea why they come when they do. (c) Fredric Neuman 2013