In a society obsessed with being happy, the emotion of sadness has been turned into a private disease, a symbol of failure. Catherine Keenan explores a problem that won't go away.
Samuel Beckett once observed that the tears of the world are a constant quantity. Sadness can be ameliorated or ignored, but we can never do away with it entirely. It is unavoidable and universal, the one emotion that most profoundly tells us we are alive. Without sadness, we wouldn't know the value of being happy.
Yet we have become so clumsy at handling this elemental feeling. Other cultures have rituals, like wearing black for a year, which make unhappiness acceptable in the public realm. But we have no such codes, and sadness is too often regarded as a shameful condition that we do not know how to admit into our lives. If someone bursts into tears, our first reaction is often to lead them away somewhere private. We will talk to anyone about our happiness, but we tend to keep sadness to ourselves: it's not polite to bring other people down. Too often, the old adage holds: laugh and the world laughs with you, cry and you cry alone.
This is most obvious in times of extreme sorrow. When Don's eldest daughter, Karen, died suddenly at the age of 20, his grief was cavernous. But in the following weeks it was compounded because nobody wanted to talk about what had happened. Scared of the emotional outpouring they might provoke, friends were reluctant even to say Karen's name. Soon they stopped phoning, or dropping round. One person crossed to the other side of the road simply to avoid having to say hello. Sadness enveloped Don and his wife, and people shunned them as if it were a disease.
Their grief was treated as an illness in other ways too. Following award guidelines, Don was given three days' compassionate leave to get over the death of his daughter. To get more time, he needed a medical certificate, so he went to a doctor and was offered antidepressants. Don thought his sadness was normal rather than pathological, but he accepted the drugs anyway. He stopped taking them when he decided they were cauterising his normal reactions and not allowing him to properly grieve.
This was 15 years ago, and since then stories like Don's have become more and more familiar. The co-director of the Bereavement Care Centre, Mal McKissock, says that half the people he sees have been offered antidepressants. Don puts the figure even higher, saying almost all the bereaved parents he has met have been offered drugs to assuage their pain.
Sometimes this is necessary grief can trigger depressive episodes. But there is no doubt that at least some of these people were simply experiencing natural sadness. Not all sadness is this profound, and not everyone finds their friends and family turn away. Women and younger people, in particular, are much more likely to find that others are willing to talk about it. But any society that deems it reasonable for people to return to work two or three days after the death of an immediate family member is clearly leaving too little room for grief.
The unhappy consequence is that too much of our sadness is ending up in doctors' waiting rooms. Even psychiatrists admit that this happens, though they emphasise it is in a minority of cases. The prescription of antidepressants has skyrocketed in Australia in the past 20 years. In 1991, depression was the 10th most frequently diagnosed condition in general medical practice; by 1998 it had become the fourth, with about 700,000 new episodes diagnosed every year. This is roughly in keeping with other Western countries. The use of antidepressants in Britain has doubled in the past decade; in the United States it is estimated that up to 10 per cent of the population takes antidepressants.
There is no doubt this has been of enormous benefit to some people. The development of new types of antidepressants, such as Prozac, has made the treatment of depression easier and less painful, and awareness campaigns worldwide, such as Beyond Blue in Australia, have helped de-stigmatise mental illness so that more people are getting the treatment they need. Even so, health professionals insist there are still hundreds of thousands of people who are suffering crippling depression in silence.
It is largely for the sake of these people that psychiatrists and others are reluctant to talk about the medicalisation of sadness. There is a group of people being over-treated for depression, but there is another group being under-treated and psychiatrists don't want to discourage them from coming forward by conflating their condition with sadness. It may be true that, as Lewis Wolpert, a biology professor and depression sufferer, has put it, ``Sadness is to depression what normal growth is to cancer." But in practice, the line between the two is shifting and unclear, and we have always had difficulty telling them apart.
As far back as Aristotle's time, people used the words melancholy and melancholia to refer simultaneously to a passing, natural mood and to a debilitating mental condition. Both terms are derived from the Greek words melas (black) and khole (bile), a reference to Hippocrates's theory that health subsisted in the correct balance of the four humours: blood, phlegm, black bile and yellow bile. The presence of some black bile, and its occasional ascendancy, was the sign of a healthy disposition. But too much melancholy, and a person tipped over into mental disturbance.
The humoural theory of health persisted for almost 2,000 years. Consequently, as Jennifer Radden writes at the opening of her history The Nature of Melancholy (Oxford University Press): ``For most of western European history, melancholy was a central cultural idea, focusing, explaining, and organising the way people saw the world and one another and framing social, medical, and epistemological norms."
It was only in the late 19th century, as psychiatry became a recognised sub-discipline of medical practice, that this idea began to fade from view. A clear distinction emerged between melancholy as a mood or disposition, and melancholia, thought of as a pathology. Soon after, however, both terms began to disappear. Melancholy, with its connotations of creativity, sensitivity, and authenticity, began its slow dissipation as it ceded ground to more prosaic sadness. Melancholia was erased much more quickly as the new word ``depression" emerged to replace it in psychiatric nosology.
But Radden argues that there is no simple equivalence between the two. The new designation of depression roughly coincided with a new way of understanding the condition, which she traces to Sigmund Freud. Although he continued to use the older term, it was with his 1917 paper ``Mourning and Melancholia" that our current notion of depression emerged, as he replaced an emphasis on anxiety and extreme sadness with an emphasis on self-loathing and introjected feelings of loss. It was Freud, more than anyone, who made depression qualitatively different from ordinary sadness.
Persistent feelings of worthlessness are still at the heart of definitions of depression. But as psychiatry has cemented its place within empirical medicine, it has also tended to emphasise functionality and more readily observable symptoms, such as sleeplessness, loss of appetite and lack of energy. This, combined with the qualified success of antidepressants, developed in the 1940s, firmed up the sense of depression as an illness like any other.
But this delineation from sadness has since become more than a little unstuck. There are many possible reasons. Once psychiatry became the repository of our mental ills, its purview began to expand, and in the past 30 years ever more specific and trivial subsets of depression have appeared. Leaving aside manic, or bipolar, depression, the bible of the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders, first divided depression into major disorders (lasting more than two weeks) and minor disorders (one or two weeks). Now it also includes dysthymic disorder (too mild to be called depression, but extending over at least two years); subsyndromal depression (for those who meet only some of the criteria for other types of depression); depressive personality disorder (again too mild for other categories); psychotic depression (with anti-social indications); and recurrent brief depression (lasting only days, but reappearing over a 12-month cycle).
Professor Gordon Parker, head of the school of psychiatry at the University of NSW, and Professor Philip Boyce, of the University of Sydney, agree that this ever-widening definition has cast the net too wide. Inevitably, it allows natural grief and sadness to be regarded as treatable conditions, and risks robbing depression of any real meaning.
Both professors also note that pharmaceutical companies benefit the most from this. Americans alone are estimated to spend about $US890million ($1.7billion) every year on antidepressants: the wider the range of indications, the more this billion-dollar industry will expand.
Antidepressants are only effective for about 70 per cent of people, but unfortunately they are too often seen as a quick fix. For most Australians, a GP is the first port of call if they feel overwhelmed by sadness; sometimes, as in Don's case, this is not through choice but necessity. But the average GP appointment is five to six minutes, nowhere near enough time to determine if a person's grief is appropriate to their circumstances, so handing out pills is the easiest option.
Interestingly, this happens more often to women than men. In her history, Radden notes that just as melancholy was aligned with profundity and genius by Aristotle in the classical period, by Ficino in the Renaissance, and by poets such as Keats during the Romantic period so, too, was it regarded for 2,000 years as a male affliction. Women only started to suffer from melancholia at the end of the 19th century, when the pathology was isolated from the mood. As Radden puts it: ``Human, redeeming, ambiguous (and masculine) melancholy" pulled apart from ``aberrant, barren, mute (and feminine) depression". Women are still diagnosed with depression at twice the rate of men.
Many explanations have been offered for this. Some say women lead more difficult lives, others argue it is because women are more likely than men to seek help for their pain. A third and more disturbing explanation is that a predominantly masculine medical establishment is more likely to view the feminine expression of difficult emotions as aberrant.
It would be unfair, however, simply to blame doctors. They could not diagnose hundreds of thousands of people with depression every year if vast numbers were not coming to them complaining about how they feel. Where once we saw a priest, a relative, or a friend, many of us now take our pain to the doctor. If they are treating that pain as illness, more of us are seeing it that way, too.
This is evident in the very language we use. Sad is a small word to describe what can be a tidal feeling. Depressed seems to gather our gloom more fully, the syllables themselves expressive of the weight we feel. Depressed also places our emotions on a medical spectrum, aligning them not with events or natural cycles of mood, but with ungovernable changes in brain chemistry. Depressed allows us to stop searching for reasons and cause. It gives us the luxury of handing over our emotional wellbeing to a trained professional.
There is a special relief in this because, as Don discovered, the unhappy truth is that we aren't very good at dealing with sadness ourselves. How we reached this impasse is a matter of conjecture, but it is almost certainly a function of an increasingly rationalist society. McKissock notes that the disintegration of the extended family leaves us more isolated, and we are often wary of the intimacy that is required to listen to someone else's sadness. In particular, it can make us confront unhappiness of our own, something we don't necessarily want to do.
But he also suggests it is because our society is founded on the illusion of control. In the way that we direct everything from the temperature in our homes to the trajectory of our careers, we also want to control our emotions, be it through a seven-step program or a pill. Progress seems to make us think we can eliminate sadness and risk from our lives, and the court system has become clogged by people who view difficult events as aberrations for which someone must be to blame. When the disruptive, unpredictable power of sadness erupts into our lives, it is a problem like the car breaking down, which we think someone ought to be able to fix. It is interesting that when grief washed over America in the aftermath of the September 11 attacks, a group of 20 psychologists felt it necessary to place an advertisement telling people not to seek counselling or other help. They thought we needed reminding of the simple, ineradicable fact that sadness is part of life.
That, it seems, is what we refuse to accept. Robert Burton, the great 17th-century writer on melancholy, wrote: ``'tis most absurd and ridiculous for any mortal man to look for a perpetual tenor of happiness in this life." But knowing this has never stopped people trying, and contemporary society seems particularly intent on making happiness the rule. Perhaps it is because we no longer have religion, which promises spiritual rewards for a good life, that we now seem to value the happy life above all things.
Unlike other generations, we are also offered a bewildering and conflicting array of ways of achieving it. We are promised happiness in everything from new cars to deodorant and holidays. It is proffered to us on every billboard, in every television commercial and on endless magazine covers. In the absence of any other reason for being, happiness takes on the character of a religion and sadness is pushed firmly aside. If happiness is the goal, then unhappiness becomes a kind of failure, and succumbing to it is akin to letting the side down. Even strangers in lifts feel entitled to tell people to cheer up, it cannot be that bad.
Whatever its cause, there is no doubt that our denial of unhappiness has a huge social cost. As Don discovered, it isolates us when we are most in need of intimacy and adds to grief the burdens of shame and incomprehension. Antidepressants can help those who are depressed, but like psychotherapies, all they do for the sad is whittle away autonomy and decrease resilience. Worst of all, by shutting out sadness and hiving it off as a pathology, we diminish our sense of what it means to be human.
The extent to which we can give ourselves up to sadness determines how fully we can experience joy. In his extraordinary book The Noonday Demon (Chatto&Windus), Andrew Solomon writes that despite its almost unbearable pain, it was only in depression that ``I learned my own acreage, the full extent of my soul".
By medicalising sadness, we also run the risk of forgetting its redemptive power. Aristotle thought melancholy men the wittiest, and marvelled that anyone who had become outstanding in philosophy, statesmanship, poetry and the arts was tinged with more than a touch of black bile. Some of these men probably had what we now call depression, and there can be little doubt they would have traded all their achievements for the sweet relief of modern pills. But to wish away sadness, too, is to wish for a fool's paradise.
It is telling that the word melancholy has fallen into virtual disuse. It seems better to remind us that sadness is what stretches us, what spurs us on to create, and urges us to seek out meaning for our lives. It reminds us that mild unhappiness can be a gently pleasurable state of contemplation and quiet truths. Burton said melancholy was many things: sad, sour, damn'd, harsh, fierce and divine. But above all else, he knew there was ``none so sweet as melancholy".