Ep. 53 - Why Feeling Depressed Doesn't Always Mean Depression

Depression, anxiety, and other emotional struggles can look similar on the surface, but they don't always come from the same place. Sometimes what feels like depression is grief, overwhelming stress, disappointment, or anxiety wearing a different face.

Dr. Andrew Rosen and Dr. David Gross walk through how experienced mental health clinicians sort through those differences. They explain why the first complaint isn't always the final answer, how they distinguish biological, psychological, and social factors, and why understanding someone's story matters just as much as identifying their symptoms.

Along the way, they explore the importance of language during an evaluation, why treatment often happens in stages, and how personality, childhood experiences, and long-held patterns can shape the way people respond to life's challenges. They also discuss why mental health care is about more than reducing symptoms, helping people build healthier ways of thinking, coping, and moving forward with realistic hope for recovery.

Contact the Docs:

Email: twoshrinksandamic@gmail.com

Transcript

SPEAKER_00 0:08

Hi, I'm Dr. Andrew Rosen. I'm a psychologist.

SPEAKER_01 0:11

And I'm Dr. David Gross, and I'm a psychiatrist, and we are two shrinks and a mic. Today we'd like to talk some more about uh the the challenges we have as mental health professionals. That is, how how do we figure out what the problem is? And then once we figure that out, how do we then come up with a plan of treatment? And I think it requires uh a better understanding of uh the nature of the human psyche or personality. And one way of understanding that is to view it in terms of uh uh of mood, sadness, happiness, anger, irritability, uh, etc. Thinking, you know, whether or not your thinking is uh rational, whether or not it's uh broken record obsessive thinking, uh, whether or not there's a content to your thinking that indicates the kind of emotional state that you're in. Uh, and finally, uh behavior, uh, which is uh simply speaking, you know, whether or not you're staying in the house all day long under the covers, or whether or not you're agitated, uh uh making lots of phone calls, speaking rapidly, et cetera. So when we see an individual for the first time, we try to understand which of those realms appears to be the problem. Um the challenge for us is that individuals can come in with what we call a chief complaint, like the main problem, what's wrong? And they'll come in and they'll say, you know, I'm depressed. But at the end of the day, when we do our evaluation, it may not be uh true depression. Depression may be a secondary effect of whatever else is going on. So it's a process that we go through that uh big that begins with the chief complaint, but then we need to like get into more intensive uh uh evaluations.

SPEAKER_00 1:49

Yeah, the chief complaint is is where we start. It's um, you know, you and I both will say, so in something like, so what brings you in to see me today? You know, what's happening in your life? And uh depending upon that main uh complaint, we will take it from there. But let's say a person comes in and they say, Well, Doc, I'm I feel depressed. So first thing we want to do is, well, could you tell me more about how that feels what when you say you're depressed? Could you describe it? Uh and and so we can get a clear pretty clear picture of what that depression feels like. You know, for some people it uh will be uh explained as I feel uh sad, I feel hopeless, I feel guilty, I feel like I don't have anything. So it may point in a direction of loss, it may point in a direction of uh guilt, uh feeling guilty about things that maybe uh the person should feel guilty about or maybe shouldn't feel guilty about. Uh but w we try to go down what we call a decision tree in terms of trying to figure out, well, what might be causing this depression? Does it look like there are situational factors in the person's life that uh would lead a person to feel depressed, like loss or a change of uh uh job or a disappointment, a breakup in a relationship, those kinds of things. Or it's hard to identify a situational factor, and maybe it's a different kind of uh motivation for the depression, like more of a uh uh uh uh brain thing, a chemical thing, as opposed to a life circumstance. Depending upon how that fork in the road goes, then we we just keep going to see uh what might be uh the current triggers. Maybe there are old triggers, how long has this depression been in a person's life? Is it uh going on for a long time? Is it recurrent? Did it disappear for a long time? These are the kinds of questions that we that automatically come up in our minds as uh the clinician, and we'll ask questions that will then give us more and more of a refined understanding as to what is the problem, what may be the cause of the problem, and then eventually we'll get to what can we do about it.

SPEAKER_01 4:08

You know, we've talked about this a lot uh on previous podcasts, but the reality is that words are cheap, and I don't mean that in a in a really negative critical fashion, but language is critical in our ability to evaluate what's going on. We we we uh unlike a uh cardiologist who can get an EKG and put somebody through a stress test, we really have nothing like that. So we really rely upon the spoken word. And I tell people all the time that your subjective input to me can make the difference in figuring out what's wrong. Because, for example, people will come in and say I'm depressed, but in fact they they may be sad because of a life situation, and no medication is going to change the life situation when they come in to see a psychiatrist. I tell them that. And you know, oftentimes people are are disappointed if I say that, you know, this is a psychological life situation type of problem, and and it's best really worked out in in psychotherapy to help you better understand the nature of the problem and to come up with strategies to to cope with it better. Um but the language that's used is important, and and like you just mentioned before, the getting people to be as specific as they can about what it's like to feel the symptoms they're having, or what it's like to to feel like you don't want to get out of bed or you don't want to talk to anybody. Uh, do you feel sad most days? Is your thinking negative? Um, do you feel like uh giving up, running away? Or as much language as possible that can be contributed to the evaluation makes my job easier. Uh and then the next challenge is to determine how much of this has led to an endogenous shift. By endogenous I mean an internal biological change. The worst aspect of uh mood disorders like depression or anxiety disorders is when people feel like they're stuck and trapped in that state. And no matter what they do, they can't get out of it. I've had people who have been uh clinically depressed who'll go on a wonderful cruise and feel miserable the entire time on the cruise. When I have individuals who tell me they've been miserable at home and depressed, and then they go off on a vacation, they feel great and interact normally. That's an indication that there is not as much of a biological, internal, or endogenous change as one would think, that it's more related to situational and psychological factors that need to be addressed in a different manner. Um so understanding how much of this is an ongoing uh it's almost like the fog has come in and the sun isn't burning it away type of state that requires uh uh intensive treatment to get the individual better. Um the for me, the the the key in in an endogenous or biological state is when they tell me they feel like they fell into a a dark hole or a dark well and they can't get out no matter how hard they try. Uh that that tells you that there's something that has been overwhelming their their brain systems of recovery so that they can't they can't control it and they can't get out of it and they need help. And that's where that's where combination of medication and talking therapy could be most helpful.

SPEAKER_00 7:01

And very often in the endogenous example, a person can't really identify anything in their life that's really bugging them that much. It's not like they're gonna complain about this person or their work or yeah or something that's happened. They just feel bad and they've been feeling bad for some degree of time, and they don't really know what to do about it other than continue to feel bad. And so uh that's that right away that gives you a different feel as to what might be the type of depression that the person might have. Same thing with anxiety. I mean, some people will say, you know, I know I suffer from anxiety, but I really don't worry about anything. And you know, it's hard to imagine that that exists, but there are people who will feel anxious, and they can feel anxious mentally and meaning they're fearful, and they can feel anxious physically where they feel jittery and just not calm. And then when you ask them, is there anything you worry about, they say, you know, I I'm not a warrior. I don't I'm not a negative thinker, but I just feel anxious. That's the kind of person that may be much more on the the biological end of this continuum that has a nervous system that generates anxiety or or a sense of uh apprehension. And uh then on the other end of the continuum, we know there's the person who, when we say, What's your anxiety like? They'll say, Well, I'm always worried. The glass is always half full. I'm always thinking something bad's gonna happen. And so uh then we would look at, well, has anything bad really happened? Because if the person has had bad things happen, it's a whole different uh schema than if a person is just worried about bad things happening, but they really can't identify any particular bad thing that's happened in their life. So these are all little things to to the average person that uh uh seem like maybe not such important details, but for us, they're like flags that go up. They're just either going to be green, yellow, or red, but they're flags that tell us which direction to go in. So by the time we may go through an hour or two of interviewing somebody, we should have a pretty good idea as to what's the diagnosis, pretty good idea as to the type of problem it is. Does it seem more bio, or does it seem more psychological or even social? And then we can have a pretty good idea as to how do we want to go about helping this person uh resolve these kinds of problems.

SPEAKER_01 9:37

Aaron Powell And you know the the context in which the uh change in the mental state occurs becomes critical. I mean, at the end of the day, when we put together uh a diagnostic plan in our heads and a treatment plan, it's a multi-part attempt, meaning what what what needs to be done acutely. So, for example, if a person um is uh terribly depressed and has a clinical biological depression, uh and you can almost visualize the imbalance of brain chemicals that cause the abnormal electrical firing in the brain centers that cause the depression. But if in the context is a life that uh is stressful, marriage failing, uh job pressures, school difficulties, um then we recognize that um this is the kind of depression that's going to be a bit more difficult to treat than just a depression that exists within a a pretty normal, healthy life situation where there really aren't any factors that are influencing one's emotional state. Um, because recognizing that the that the depression can be treated initially as the first step with medication and talking therapy, but at the same time, the context in which it occurred needs to be addressed. Um not necessarily saying that the marital difficulties or the job stresses are causing the depression, but they're certainly having a negative impact upon the ability to cope with it. So once the depression begins to clear, the next part of our multi-part treatment plan is to address the stresses that were there to begin with. Um there are individuals who, because of their genetic makeup, um are predisposed to depression and their life could be perfectly fine, and out of the blue, they'll come into a depressive state. But then there are individual there are other individuals who don't have that kind of genetic makeup, but their life situation is so difficult and stressful and impossible that through the stress itself, uh, the biological changes in the body and the brain that occur can lead to that kind of depressive state. Uh and that we've seen in individuals who are survivors of war trauma or other traumatic experiences in life. Um and in that case, then we need to pay attention to treating the depression, uh, recognizing that there was a perfect storm for that individual in their life situation, and they were being hit from all sides with stressors, and that's probably what triggered the depression. And then there are other individuals, as we discussed before, who when when life is relatively stable will be fine. But they may have a genetic predisposition to be sensitive to significant life stress. So when it occurs, it can push their biochemistry and their brain to a point where they develop a depression. Uh and then when they recover from the depression, if life is then reasonably stable and and unstressful, it'll do fine until the next bump in the road. Um there's a tough decision there in terms of making a decision about medication and whether or not one should be on it indefinitely. And so the context becomes critical as we pay attention to what turns out to be a multi-part, multi-step treatment plan.

SPEAKER_00 12:35

And there's another we talk uh uh uh quite a bit about this biological bio-psychosocial model, which is that we're all a combination of these three components, the biological part, the psychological part, and the social part. Um and you know, the psychological part really refers more to the internal world of the person, you know, how they um think about themselves, their self-esteem, their um feelings about how they are as a person, their whatever guilt they might be feeling or fears they might have. The social part is another aspect of of what we look at. Um I think we're more appreciative of that social world more than ever, because one of the things I've learned to ask of people is, okay, you know, we've gotten a picture as to what your symptoms are, but let me ask you about what you feel about your role in life and and your expectations for yourself as a person in this world, and and do you feel like you've um measured up to what you would have wanted to measure up to in in living in this world? Do you feel like the world has measured up to what your expectations are of people or or of life itself? Uh because very often you might see somebody who has really worked very hard at being a gr a really good person, achieving, working hard, being a great dad or a great husband, a great wife uh and yet they might still feel depressed. And some of that might have to do with the uh internal concept that we kind of develop in childhood, and that is, you know, if I eat my green peas and I do everything I'm supposed to do, I'm gonna live happily ever after. So there's a certain idealized expectation that people have of what could happen in life and what life will be like after you've finished your job, so to speak. And very often, as we know, life isn't that way. And and life isn't uh uh a rain, you know, a kind of end of the rainbow and and celebration after you've done all of the hard work to be the best person you can be. So very often there's a depression that comes about from that, like a disappointment. I was look I was so looking forward to a certain point in life where things would be so nice, and then even if nothing bad has happened, no traumas, no losses, nothing bad, still a person could feel this vague, diffuse feeling of disappointment, and that can lead to depressive feelings. So it's kind of complicated. It's important what we do is to look at all of the potential intervening variables that can impact on mood or anxiety or or other psychological states, and try to put together uh kind of a hierarchy. What seems to be the most significant one right now that we have to deal with? Is it the biological, is it the psychological, is it the social? And and then, you know, kind of like have a uh one, two, three, four, and five-step process to see, okay, we can we can get the person chemistry better, but that doesn't necessarily impact on their view of themselves in this world or their view on the world and and and maybe making some corrections in in their uh expectations of themselves and of and of life. It's important to do that, and very often people aren't even aware of these things that they might be contributing to their mood.

SPEAKER_01 16:06

Well, you know, the the the analogy I often use and and what makes our field so different than other fields of medicine is I mean, if you're if you're suffering from rapid heartbeat and it's uh scary and you feel the adrenaline surge and and you wonder if you're having a heart attack and you're weak and you're short of breath, and you go to the cardiologist, the cardiologist uh is very much business-like and will send you for tests and then we'll say this is what we're gonna do to treat it. But the cardiologist will not necessarily ask you what it's been like to deal with these symptoms, uh what it's like to have spent the last two weeks having these bouts of rapid heartbeat where you think you're gonna die or have a heart attack. But we're different because we we not only recognize the nature of the symptoms, but then we ask an individual what it's like to deal with them. You know, so what what what has been it like what's been like to have uh this sad mood where your friends are looking at you and saying, What's wrong? and and your spouse is saying, uh, you're not the same person that I I know. Um and that gets back to the concept we raised in the past in one of our podcasts, where we've talked about the difference between disease and illness. The disease process is the uh biological change or the life situation change that causes the anxiety or the depression. But the illness is how the individual reacts to this symptom. And both you and I have talked a lot about individuals we've treated together who get real good at beating themselves beating themselves up over having anxiety or having depression, saying to themselves, you know, well, I should be stronger than this. I'm allowed, I must be a weak person to let this happen. And people get into that kind of self-negative, self-critical thinking that if anything makes the anxiety or the mood difficulty worse. And so we have to recognize that part of our job is to help the individual begin to confront their tendency to beat themselves up irrationally, that this is a process that's occurred, there's no reason for you to self view yourself as inferior or weak or not as good as anybody else. And we've got to work on helping you get out of your own head and start and stop uh beating yourself up, which is why we tell people all the time to do things that will distract themselves, go to the gym, read a book, go for a walk. But the more you stay by yourself in an anxious or depressed state, stuck in your head, the worse it's gonna get. Um, and that can just feed into it. And so recognizing the impact of of illness is just as important sometimes as recognizing the impact of the disease process itself, whether it be anxiety or mood. Um and the disease process in many respects is easier to address because we have treatment protocols that address that directly. But getting to know that individual and their personality style and the state of mind, whether they're a cup is half full thinker, a cuppa's half-empty thinker, whether or not they're raised in a family where, you know, they were told repeatedly to have a stiff upper limp, never li a stiff upper lip and never complain. Don't show you don't show your emotions, be a prim and proper person, that's important to know because that's going to in impact upon the illness aspect of of how they cope with a particular disease process that they're dealing with at the time. And so as you can see, f for us it's a much more complicated picture than it is for a cardiologist or a gastroenterologist or even your primary care provider.

SPEAKER_00 19:25

And you know, uh in terms of how do we help the person. Well, okay, we have definitely on one side of this uh equation, we have medications that uh uh target symptoms. And then we also have uh psychotherapeutic methods that target symptoms. Those tend to be more uh, you know, if it's anxiety or depression, we have things that we can help a person learn to do or to how to think differently or uh how to go about uh conquering a particular fear. It's very uh specific. It's it's uh more teaching than anything else, giving skills. Uh but then beyond that you can have a person who has ameliorated their symptoms but still have a sense of uh I'm not okay. I'm just not happy. I don't have symptoms. As somebody said to me yesterday, you know, I'm not anxious. You've really helped me with my anxiety, but and so very often the but has to do with issues of uh self-esteem, has issues to do with uh is this what life is, is this is what it's all about, issues related to um what's the meaning of life, what's the my purpose. And so, you know, if we go back uh the whole circle of where we were as a mental health field maybe a hundred years ago, well we used to talk a lot about the relationship with your parents. And it was probably overdone in many respects, but still, I still ask people um who don't necessarily have a problem with their parents, and maybe the parents aren't here any longer, um, how do you feel like you've measured up to what you thought your parents would have wanted for you? And very often they have to really think about it. They they're not conscious of even ever having thought about it. But somewhere in their psyche there might be a, you know, I'm I I I'm not sure if I lived up to the thing that I thought I was supposed to live up to when I was a child. And even that can play a role for the person who has accomplished everything and does have everything materially and and family and everything else. And they can still feel that disappointment or that loss feeling because maybe that has to be, you know, some connections made there to see uh what some of the thinking is in there and the feelings that exist. But again, it's complicated. It's it's in some respects, it's very simple what we do, because we know what to do and we know where to go to look for things, but at the same time, it's complicated. Because human beings, we are very complicated.

SPEAKER_01 22:04

Well, you know, maybe somewhat simple for us because of all the years of experience we've had, but for for as you say, for the individual who comes in to see us, we're often the last step in the line of an attempt to get treatment. Um both of us have treated individuals with anxiety panic disorders who have already seen a cardiologist, a pulmonary specialist, a family doctor. Uh, and it's only at the end that they're told that this is probably an anxiety psychological problem and you and you should see a mental health professional. So we're the the last step on the on the on the trip, and for a lot of people they view that as a sign of of failure. That it's it's it's if if the cardiologist could have treated this problem or the pulmonary doctor could have done it, it I I'll have saved face. But coming in to see a mental health professional, it's almost a sign of, oh my God, it's the last step. And so people are very anxious when they come to see us because of what it means to see a mental health professional. And a lot of what we need to do in the beginning is to let them know that, you know, this is not the first case of this type of problem that we've seen, that you're not alone. That that this is a common problem. And most people who come in to see us feel like they're they're unique and then that their their suffering is is is their own problem and and that it's it's it's it's it's it's unique to them and nobody else has a type of problem. And when they hear that other people have gone through it and recovered, it helps tremendously. So they're scared when they come to see us quite often, and part of our initial task is to reassure them that this is not different than any other aspect of of healthcare and medicine, in that we need to identify the nature of the problem, come up with a treatment plan, and give you a sense of self of of of recovery. The the the cases that are most difficult for us are the ones that involve individuals who have had what we call maladaptive behavior personality traits, individuals who have their own way of dealing with the world that gets them into trouble repeatedly. It's not like having an episode of anxiety or an episode of depression that you can define coming on out of the clear blue or in response to life stress and has developed a life of its own. But individuals who have spent years or decades with maladaptive traits and poor relationships, poor marriages, drug abuse, uh problems interacting with other people because of their psychological makeup, that's more of a challenge because if you think about it, uh it's almost like imprinting. They they've been conditioned into being this way. That's the only thing they know. To try to teach them new techniques and new ways of dealing with life can be very difficult because people often will resort to the path of least resistance, uh something that they've known the best. And uh I frequently tell people that look, this is the way that you know the best, so all the stuff that we're talking about now is brand new and difficult. And we recognize it's gonna be difficult, it's gonna be a struggle because you're going to be trying to break the mold of behaviors and ways of thinking that you've had for years and sometimes even decades. And it's gonna take time, it's not gonna happen overnight. But if you can hang in there with it, the brain is malleable and personality traits are malleable and they can change. And people can begin to recognize that I can toss away some of these maladaptive traits and gain some of the healthier ones. Uh, and that's really rewarding when you can see it happen. But it's uh it's a different type of problem than dealing with straightforward depression or even anxiety disorders.

SPEAKER_00 25:28

I uh have developed a a way of putting it to people that uh something like this, that for for whatever reason, uh the operating system that you were given when you were a child that was sent from the factory, it worked okay, but that operating system is no longer working well, and it's helping you make bad choices. And so you p you p put, you know, you type in things into the computer, but it's giving you information that's really either useless or bad. So what we're gonna do here is try and give you a new operating system that will help you make better decisions and then do your thinking process in a in a more healthy way than the operating system that you've been using. And people can a little bit better relate to that. They can see, okay, I get that. Um and uh that's where we start. So we're gonna give you an opera new operating system, and here's here are some of the components. I'm gonna tell you what I want you to read for the next few months, what I want you to work on, what we want to talk about, what we want to think, so we can put in some new new things into your operating system. But it's it's tough.

SPEAKER_01 26:39

Everybody knows the Cinderella story. What people don't know is that the ending where Cinderella goes off with the prince to live happily ever after is really a mistruth. Think about it. Cinderella spent decades of her life being basically a slave to her evil stepsister or stepmother, uh, treated like an inferior human being. And for her to suddenly change her thinking and embrace the prince and the wealth and the riches of the castle and the people who supposedly love her is a very difficult task. And uh if they really wanted to tell the Cinderella story part two, they would talk about Cinderella getting into therapy to help undo the uh belief systems that she developed from childhood, which I basically call childhood myths that need to be exposed and thrown away. Uh and that's uh that's a major task, but it can be done. And and there is hope, and people do get better. And I'm Dr.

SPEAKER_00 27:32

David Gross, psychiatrist. And in the line of your talking, I'm Martin Scorsese. I mean I'm Dr. Andrew Rosen. I'm a psychologist, and thank you for listening to Two Shrinks in a Mike. Bye bye. The Two Shrinks in a Mike podcast is for informational and entertainment purposes only. The views expressed are those of the hosts and guests and do not constitute medical, legal, or professional advice.