Co-authored with Paul Nestadt, M.D.
When he was 63, Edward* was diagnosed with lung cancer. He was lucky enough to have access to the newest forms of radiation treatment and chemotherapy, and he had three pretty good years. He continued working, and he and his wife took several trips they had been planning for retirement. His son got married, and he enjoyed the wedding and its celebration of the continuity of life. He was overjoyed when his son told him that he would be a grandfather. But then he learned that his cancer was spreading again and that, short of a miracle, he would not live to be a grandfather. The thought that he would not live to see his grandchild tormented him, and he became very "depressed."
Did Edward have a diagnosable mood disorder or was he simply and understandably unhappy that he would die before his time?
Some mental health professionals use the concept of "demoralization" to distinguish between depressive disorders and sorrows that are part of the human condition. This is a very important distinction that people suffering emotional turmoil, their family and friends, and their doctors should keep in mind before giving or accepting a diagnosis of major depressive disorder and particularly before turning to antidepressant medications to ease their emotional pain.
What is the difference between a depressive disorder and demoralization?
Strictly speaking, a mood disorder is a psychiatric diagnostic category that is defined in a diagnostic system such as the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) or the International Classification of Diseases (ICD). These systems provide official diagnostic guidelines that health and mental health professionals use to determine whether a person has a mental disorder.
In the DSM, there are a number of diagnostic categories related to a depressed mood, including major depressive disorder, bipolar disorder, dysthymic disorder, and certain adjustment disorders. Some mental health professionals also use a diagnosis of minor (sometimes called "sub-syndromal") depression.
A diagnosis of major depressive disorder requires that a person has experienced either a depressed mood or the loss of interest or pleasure in most activities and four additional symptoms such as thoughts of death or suicide or changes in appetite, sleep, or activity, for at least two weeks. Minor depression has fewer and less severe symptoms. Dysthymia is a depressed mood that lasts two years or longer. And adjustment disorders are reactions to a distressing event, such as a serious physical illness, that is "in excess of what would be expected" and/or involves "significant impairment in ... functioning."
In contrast, "demoralization" is generally defined as "persistent inability to cope ... associated feelings of helplessness, hopelessness ... subjective incompetence, and diminished self-esteem," which also involves a challenge to one's sense of meaning or purpose, but is not more than would be expected under the circumstances.
Although demoralization can occur in response to many distressing circumstances including long-term unemployment, displacement due to war or a natural disaster, imprisonment, etc., much of the literature about demoralization focuses on people who have a terminal or severely disabling physical illness or injury and are extremely distressed about it.
Knowing -- like Edward -- that I will die soon or that I will be paralyzed for the rest of my life or that I will have to live with severe pain either for the short time I have left or for many, many years to come can evoke powerful, emotionally-charged questions. Did I do enough with my life? Have I provided for my children? Has my life had meaning? What will I be after I die? Facing questions like these can -- needless to say -- be terribly upsetting and evoke or reflect a state of demoralization.
Truth be told, distinguishing between depression and demoralization can be difficult. It requires consideration of how severe the symptoms are, whether they are an understandable reaction to troubling circumstances or are excessive, and whether there is a history of mental illness prior to the current situation. Even professionals sometimes disagree.
Mental health professionals also don't agree about whether demoralization should be regarded as a specific diagnosable mood disorder. The DSM, for example, does not include demoralization as a diagnostic category, but the ICD does.
Nevertheless, the distinction between major depressive disorder and demoralization is important, and it matters which diagnosis is made, if only because most of us don't want to be diagnosed with a disease we don't actually have, whether it's depression or diabetes.
In addition, characterizing a person's emotional pain as major depression or as demoralization influences the choice of intervention. A diagnosis of a major depressive disorder tilts us in the direction of prescribing antidepressant medications, which recent research suggests are not more effective than placebos except for people with a severe major depressive disorder.
Characterizing a person as demoralized may lead to more appropriate, non-pharmacological interventions such as engaging in satisfying and meaningful activities, maintaining caring relationships, spiritual counseling, meditation, life review, physical exercise (including yoga) to the extent possible, and -- very importantly -- psychotherapy. In fact, Jerome Frank, who developed the concept of demoralization 60-plus years ago, said that it was probably the primary reason why people seek psychotherapy. He believed, as do many others today, that psychotherapy can be helpful for some people struggling with sorrows that are part of the human condition, whether or not they constitute a diagnosable mental disorder.
A full professional workup can help to differentiate demoralization from a major depressive disorder. Troubling moods can arise from a variety of contexts. They may indicate a major mental disorder, but could also represent reactions to life circumstance, personality vulnerabilities, or patterns of behavior. The handling of the sadness must match its source. So, when you or someone you care about has a frightening illness or is caught up in other human troubles and is "depressed," it can be important to ask whether they are clinically depressed or demoralized.
Michelle Beth Iankowitz, a student at Columbia University School of Social Work, contributed research for this blog post.
(Paul Nestadt, MD, co-author of this post, is a psychiatric resident at Johns Hopkins.)
* Edward is a prototypical case based on real cases
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