To me one of the great questions of the day is understanding the difference between being sad and clinical depression. A lot has been written on this recently. An excellent article in the Washington Post today discusses this topic and treatment for depression. Here are few of its observations. 

• To say that we live in stressful times is an understatement. Covid. The climate crisis. A country riven with tension and political discord. What’s clear is that the world we live in has taken a toll on our collective mental health. 

• But it is never too soon for people to wonder whether they are just stressed and sad — or clinically depressed. 

• Feeling sad is normal, but depression is not. It’s a critically important distinction. Feeling distressed and sad is a normal and expected response to what we’ve endured these past several years, including the social isolation and loss of human life brought about by the pandemic.

• But unlike everyday sadness, clinical depression is never a normal response to stress or trauma; it’s a serious medical illness that is associated with significant impairment in our ability to function in major areas of our life — in relationships, at home and at work. 

• So how can you tell if you are depressed or just plain sad? 

• To start, depression is a syndrome that involves far more than sadness. Aside from a sad or flat mood, depression typically causes insomnia, loss of libido and appetite, social withdrawal, low energy, feelings of hopelessness and suicidal thoughts, feelings and actions. 

• Sad people are unhappy about a specific event, while depressed people feel bad about themselves and have a loss of self-confidence. 

• There is abundant scientific evidence that clinical depression is associated with distinct brain changes in circuits that regulate mood, sleep, energy and appetite.

•  Brain-imaging studies have identified multiple regions where there is altered activity or structure in people with depression. 

• The notion that depression results from a chemical imbalance of any neurotransmitter such as serotonin is simplistic and wrong. 

• Depression isn’t a disease of a single neurotransmitter or brain circuit, but more likely a system-level disorder involving multiple pathways and their related neurotransmitters. 

• We don’t yet understand what causes the biological abnormalities in depression to come about in the first place, but we think it results from a complex interaction between genes and environmental stress. 

• Still, we know a lot about how to treat depression. Both psychotherapy and antidepressants are highly effective for depression. 

• Therapy and antidepressants are most effective. Psychotherapy is a first-line treatment for people with mild to moderate depression, but when depression is severe, meaning either the presence of psychotic symptoms or suicidal thoughts and feelings, then a combination of therapy and antidepressant medication is the safest and most effective approach. 

                    “Stress and Sad.” Washington Post (Oct. 18, 2022).

A new research study was published recently that discusses how marriage transforms couples in their relationships. Very interesting. Here are a few conclusions from that study:

• Since newlyweds have to find ways to get along on a daily basis, it’s perhaps not surprising that they experience changes in personality as they adapt to partnered life.
• Wives tended to show decreases in openness to experience, perhaps reflecting their acceptance of the routines of marriage.
• Husbands increased significantly in conscientiousness, while wives tended to stay about the same. Since women tend to be higher in baseline conscientiousness than men, the increase for men probably reflects their grasping the importance of being more dependable and responsible as a spouse.
• Husbands also became more introverted over the first year and a half of marriage. Other research has shown that couples tend to shrink their social networks after they wed, so this decline in extraversion reflects that trend.
• Husbands showed a slight increase in emotional stability, but it was not statistically significant. Wives, however, showed a much greater increase. In general, women tend to report higher levels of neuroticism (emotional instability) than men, so it appears that the commitment of marriage had a positive effect on the wives’ emotional stability.
• As husbands and wives negotiate life together, the best predictor of whether their marriage will thrive is the personalities of the two individuals as they enter the relationship. Emotionally stable partners make for emotionally satisfying marriages; for others, the journey is much more likely to be bumpy.

                          “How Marriage Transforms Us.” (October 2022).

There is a good article in the recent issue of PSYCHOLOGY TODAY. It discusses why people forgive their cheating partners. The following are some excerpts from that article.

• Infidelity is a relatively common occurrence, estimated to occur in 20–25 percent of marriages and close to 75 percent of dating. In the aftermath, the partner who was cheated on can experience a variety of unfortunate symptoms, including posttraumatic stress symptoms, depression, and anxiety.
• This is particularly true when attributing responsibility to the partner who was unfaithful.
• The following are some reasons why infidelity is forgiven. If she/he shows me that she/he has truly regretted it.
• If infidelity was casual and not recurring.
• If she/he gives me a sound excuse.

• If she/he swears that she/he will not do it again.
• If she/he shows me that he really wants to be with me.
• If I love her/him.
• If it was the first time she/he did it.
• If she/he confess it on her/his own.
• If she/he did it only once.
• If she/he persuades me that she/he truly loves me.
• If it was a frivolous act.
• If she/he was drunk when she/he did.
• If we have been many years together.
• If I believe that I led her/him with my actions to be unfaithful.
• If we have a good time together.
• If she/he did at the beginning of our relationship.

“Why Do People Forgive their Cheating Partner? (Oct. 2022).

     With rising inflation and economic uncertainty, unfortunately, some couples are skipping therapy to save money. There is a good article in the Wall Street Journal discussing this difficult situation. My bottom line is that therapists need to work with clients that are having a difficult economic time. Economic stress merely compounds so many other issues. Here are a few major points made by this article. 

• U.S. inflation has been rising at the fastest rate in four decades. Many are putting off therapy sessions or forgoing them altogether. 

• Nearly a third of American adults in therapy say they have had to cancel a session because they couldn’t afford it and nearly half say they would have to quit if their out-of-pocket costs increased. 

• Healthcare spending was down 7% in July from September of the year prior. 

• People are experiencing more stress, there’s an exacerbation of chronic illness, they are having sleeplessness, they’re using more substances. 

• Many therapy providers say they are largely unaffected by inflation-driven dropouts thanks to wait lists that have amassed throughout the pandemic. 

“Some Americans Skip Therapy to Save Money.” Wall Street Journal (8.25.22).

A recent article in the Wall Street Journal describes recent research that discusses the benefits of anxiety in the workplace. That it can lead to really good performance and in fact excellence. Here are a few excerpts.

• Over the past decade, research has also shown something that many scientists didn’t expect: higher levels of dopamine, the “feel good” hormone, when we’re anxious. 

• Individuals who learned to reframe their anxiety as an advantage, compared with those who didn’t, performed better under pressure, were more confident and showed biological signs—steadier heart rates, lower blood pressure—of being focused and engaged. The study showed that when we believe anxiety is a benefit rather than a burden, our bodies follow suit and better prepare us to meet the challenges ahead.

• A sense of purpose doesn’t mean some grand vision or a burning life mission. Purpose refers to the values and priorities that make us who we are and give our life meaning. 

• That’s why it’s crucial to channel the benefits of anxiety, like persistence and hope, toward purpose. 

• People who tended to pursue excellence over perfection in these exercises made mistakes, but they came up with more—and more original—answers.

“In Praise of Anxiety.” Wall Street Journal (May 7, 2022).

The problem of antidepressants when they stop working is a significant issue. A recent article discusses this critical situation. The following are excerpts from that article “Depression Drugs Often Suddenly Fail to Work” that appeared in the Wall Street Journal recently (February 17, 2022).

• You’ve been on the same antidepressants for years. Then suddenly, the medication seems to stop working. The problem can hit people even when a drug has worked well for a decade or more. Symptoms such as persistent sadness and a loss of interest in favorite activities resurge. Identifying the right solution can be difficult and largely trial-and-error: Some patients may need a higher dose of the same medication, while others may need to try a new drug or a new combination of drugs, doctors say. 
• There are no statistics on how frequently antidepressants seem to suddenly fail in people who had been doing well on them. But psychiatrists say they see it fairly regularly. 
• Scientists aren’t certain exactly why psychiatric drugs appear to lose effectiveness for some patients. There’s some evidence that long-term antidepressant treatment may reduce the number of serotonin receptors in the brain, says Dr. Nemeroff. Serotonin is a neurotransmitter, a chemical that transmits messages between neurons, that is important for mood.    
• People who have lingering symptoms of depression while undergoing treatment, such as continuing sleep problems, are also more likely to experience a relapse or what may seem like a failure of their antidepressants.
• Alcohol and drugs can destabilize mood and bring on symptoms, as can a change in sleep schedule. Other medications can interfere with antidepressants’ efficacy. And sometimes what a patient thinks is the medication failing is actually a side effect that can occur with long-term antidepressant use: emotional numbing or apathy.
• The easiest move is to raise the dose of the drug the patient is currently on, says Maurizio Fava, psychiatrist-in-chief at Massachusetts General Hospital. 
• Some psychiatrists prefer switching patients to a different class of medication. The most common switch is between an SSRI and a serotonin and norepinephrine reuptake inhibitor (or SNRI) like Effexor. SNRIs affect the action of serotonin and the chemical norepinephrine, which is involved in alertness and arousal. Dr. Schwartz says there is some evidence that SNRIs may be more effective at treating depression symptoms.
• There are potential pitfalls to switching. Besides the possibility of new side effects, people may have withdrawal symptoms from their current medication. It can take several weeks before patients feel the beneficial effects of the new drugs. The biggest danger is that the patient won’t respond to the new medication—and that the old drug was actually helping more than perceived. Patients should work closely with their doctors and monitor their symptoms to continue making adjustments to their treatment until they improve.  

 There’s a good article in today’s New York Times discussing how all couples change. Here are a few of its observations that I believe are very helpful — especially during the current pandemic.

• We don’t marry one person as much as we marry one version of a person, a snapshot of who we (and our partner) are individually and to one another at the moment when we say “I do.” Who we are five, 10 or 40 years later is anybody’s guess.
• People change. As a result, relationships change, too.
• Not only do relationships change with time, but people change, which can affect the relationship dynamics as well.
• Personalities are more malleable than we may think. Most of us change, though often gradually.
• But the pandemic and the disruption it brought have resulted in a period of far more rapid, intense and often negative change for many people the world over.
• Communication has and will always be the key to mitigate negative feelings around change in your relationship,
• Sometimes change is precisely what the love doctor ordered in order for two people to realize they are right for one another.
• Accepting changes that you can live with not only leads to more self-fulfillment but can also lead to a stronger relationship. Change brings back some of that ‘newness’ and can add new passion and interest to the relationship. 

          “Watching a Partner Change is Hard.” New York Times (January 10, 2022).

     Many relationships have thrived during the pandemic, surprisingly.

     According to recent research 74% of married couples surveyed felt the pandemic strengthened their marriages, and 82% said it made them feel more committed.  Here are three recommendations from this recent research as discussed in the recent article “How Some Relationships Flourish in a Tough time.” (January 4, 2022):

• Give Space — Perhaps unsurprisingly after nearly two years of being cooped up together, time apart is crucial to relationship health.

• Assume Positive Intent — Often we’re quick to assume the worst about a situation or a person’s intentions, a tendency that has worsened as pandemic stress wears us down. Assuming a positive attitude can be very beneficial.

• Make Time to Be Positive — Block out a specific time of day to be positive together, then stick with it no matter what.

     My initial observation is that the three above items do contribute to a better relationship between couples. Both emotionally and physically. Of course, other factors are also very relevant. But these three suggestions are a start.

     A good piece recently appeared in the New York Times discussing “languishing.” As it turns out it was the mostly widely read article in the paper for 2021. From my observation languishing has become a really significant issue during the last two years. This is true for individuals and couples. Simply put the article discusses the notion of “languishing” as a mental health issue.  Which has rarely been done before. It then makes a few suggestions. Here are the main points: 

• Languishing is a sense of stagnation and emptiness. It feels as if you’re muddling through your days, looking at your life through a foggy windshield. And it might be the dominant emotion of 2021.

• Languishing is the neglected middle child of mental health. It’s the void between depression and flourishing — the absence of well-being. You don’t have symptoms of mental illness, but you’re not the picture of mental health. Part of the danger is that when you’re languishing, you might not notice the dulling of delight or the dwindling of drive. You don’t catch yourself slipping slowly into solitude; you’re indifferent to your indifference.

• While finding new challenges, enjoyable experiences and meaningful work are all possible remedies to languishing, it’s hard to find flow when you can’t focus.

• Give yourself some uninterrupted time. I don’t think there’s anything magical about Tuesday, Thursday and Friday before noon. The lesson of this simple idea is to treat uninterrupted blocks of time as treasures to guard. It clears out constant distractions and gives us the freedom to focus. We can find solace in experiences that capture our full attention.

• Focus on a small goal. That means carving out daily time to focus on a challenge that matters to you — an interesting project, a worthwhile goal, a meaningful conversation. Sometimes it’s a small step toward rediscovering some of the energy and enthusiasm that you’ve missed during all these months.

“There’s a Name for the Blah You’re Feeling: It’s Called Languishing.” New York Times (Updated December 3, 2021).

Mental health services for students on campuses have always been underfunded. As a former board member of the Virginia Board of Counseling  and a therapist in private practice in McLean, Virginia, this has been very apparent to me. Federal law requires universities to be more responsive and proactive. This problem has only skyrocketed during the pandemic. If universities claim to be responsible institutions they have the legal and moral responsibility to do better. Here a a few comments from a recent piece in the Washington Post:

• College students nationwide are more stressed — with the  pandemic adding loneliness, worry about illness, economic distress, relentless uncertainty and churn to a time of life that is already challenging for many. Demand for mental health services had already been high, but a recent study of college students found increased levels of anxiety and isolation during the pandemic.

• Last year, the Centers for Disease Control and Prevention reported that more than 10 percent of adults surveyed in June 2020 had seriously considered suicide within the past month. Two years earlier, the share stood at about 4 percent. The issue is particularly acute for young adults. Among 18-to-24-year-olds surveyed in 2020, the CDC said, about 25 percent had seriously considered suicide.

• Campuses are a microcosm of the larger societal problem of worsening mental health during the pandemic, said Samantha Meltzer-Brody, chair of the department of psychiatry at UNC, who will be leading a university summit on mental health this month. “The needs are massive.”

• Mental health has historically been underfunded nationally, Meltzer-Brody said, “and the data is very clear that our kids and adolescents are struggling.” That will require more money and more commitment to reach students in a variety of ways, to create connections to combat the pervasive isolation of the pandemic.

• Schools across the country have taken steps to address the need, from Virginia State University and others adding days set aside for students to decompress, to Dartmouth College, one of hundreds of schools partnering with a suicide prevention nonprofit to study its mental health policies and plan changes.

• Federal officials say schools are obligated under civil rights law to address the needs of students with mental health disabilities. On Wednesday, the Education Department sent educators a letter urging steps to prevent students from harming themselves. Suicide is a perennial concern on campuses. Now officials say the pandemic has cast a new spotlight on the stress and fear students endure.

• Without doubt, students have suffered. They were shut out of campuses abruptly in March 2020. Then they endured long stretches of isolation during the last school year, whether they took remote classes from home or lived on or near campus under tight public health restrictions. And this fall is hardly back to normal.

• The data did not show any significant uptick in suicidal ideation in fall 2020 compared to fall 2019. But it did show increases in stress, social isolation and general anxiety. “These data indicate that colleges and universities should be preparing to specifically support the mental health needs of students during COVID-19, especially in the areas of academic distress, family, eating concerns, trauma, and anxiety, among others,” the center reported in February.

• At many colleges, the pandemic accelerated a trend toward providing counseling online. That continued even after campuses reopened. “Most of our service right now is still telehealth,” said Jennifer Hung, assistant director of counseling and psychological services for the University of California at Riverside.

• Now, Hung said, the university is seeking to help students through a new challenge: reentry anxiety. Coming back to campus isn’t as easy as it might seem. “How do we navigate this new normal?” Hung said. Some students need help plugging back in. “We really tailor our workshops to managing stress, managing this transition.”

          “Students Mental Health and Colleges.” Washington Post (October 15, 2021).