From time to time, patients and caregivers in the support groups that I run ask about the difference between sadness and depression. When one is profoundly sad, it can be difficult to make a distinction between sadness and clinical depression. In our daily work with patients, developing an understanding of some of the differences in the ways that sadness and depression manifest can help us to untangle these two emotional states.
One of the key factors in determining whether an emotional state falls on the side of profound sadness or crosses the line into depression is the patient's internal sense of things. Sadness of any depth, though not something we enjoy or want to face, is generally manageable. That is, we sense we can handle it. It may be painful and even overwhelming for a time, but ultimately, we feel confident that we can cope with it. Some people describe profound sadness as heavy, blue, or gray. It can be expressed by "sad" music. It might emerge as an ache or a longing. It is sometimes locatable in the body ("the hole in my heart"). We can experience this emotion yet still imagine having fun, enjoying, laughing, and finding pleasure.
Depression, on the other hand, is never OK. We sense that something is not right. Some describe depression as a black hole or a box -- a smothering, drowning, thick, black, impenetrable feeling. Sometimes one feels numb. Sometimes it is experienced as rage. Often it is simultaneously scary and sad, lonely, or angry for the person going through it. For many people with depression, even the saddest music doesn't capture the feeling. And, unlike sorrow, depression typically is not locatable in an isolated area of the body. One's whole being is overcome with it. It can make it impossible to do things, to move, to think, and to feel. When we are depressed, we have difficulty imagining anything that would give us pleasure -- ever.
The two feeling states can coexist. A person can be both sad and depressed. A bereaved spouse I worked with put it this way: "I know that I'm depressed, because I'm sliding down that slippery slope again. Thinking that death is my only way out is frightening but comforting, too. The cancer and losing G sent me downhill, but what makes me really sad is that I'm so messed up with the depression that I can't even remember the sound of his voice. Yeah, that's what makes me sad."
With cancer patients and caregivers, it is often a nurse's assessment that determines the course of mental healthcare. Making that judgment between sadness and depression can mean the difference between providing emotional support, knowing the sadness will pass with time, and discussing anti-depressant medication and making a referral to a mental health professional, because depression requires treatment. So many patients would never get the help they need if it weren't for the assessments their nurses are making every day!
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