Not Just Sadness: Decomposing Depression

I often hear my clients say, "I don't want to discuss this subject—I don't want to be sad and get depressed."

Depression is indeed accompanied by sadness, so connecting depression with sadness is common. But so is confusing these two conditions.

Sadness vs. Depression

Sadness is a normal reaction to adverse situations. It develops when expected gratification is unavailable because of a separation from or loss of something important. We process sadness by means of sorrow and letting go.

Depression is a more complex condition. In addition to unremitting sadness, depression is defined by low mood, apathy, lack of joy (anhedonia), and inability to concentrate and stay focused. Corpus Hippocraticum, the classic work published between 500 and 400 BC and attributed to Hippocrates, among other authors, includes one of the first attempts to describe depression as a medical condition. It places fear above sadness as a psychotic symptom of depression, thus postulating that fear can be a more significant factor in depression than sadness (9).

Researchers such as John Bowlby, the creator of attachment theory, have concluded that sadness often appears as a reaction to some forms of loss "of a loved person or else of familiar and loved places, or of social roles" (Bowlby, 1980). Depression is also closely related to loss and to fear that this loss will recur. Bowlby described depression as a "real or feared loss of the parent figure, either temporary or permanent," and believed vulnerability to depression derived from these early insecure attachments and experiences of early loss or abandonment.

We process sadness by means of sorrow and grieving to accept and let go of the things we cannot change. Grief tends to come in waves. In contrast, depression is unyielding. In this way, depression can be seen as the antithesis of grief. Nancy McWilliams says, "People who grieve normally tend not to get depressed, even though they can be overwhelmingly sad during the period that follows bereavement or loss" (7).

The major role of anger in depression has been long known to psychoanalytic researchers and clinicians. In his classic work, Mourning and Melancholia, Sigmund Freud, the founding father of psychoanalysis, a precursor to all modern therapies, viewed depression "as hate turned upon the self after the loss of an important love object" (1). His close associate Karl Abraham noted a propensity towards hatred in patients with depression based on temperament or early experience. The authors speculated two things: 1) the experience of premature loss creates vulnerability to depression, and 2) depression results from anger turned inward in response to loss.

The melancholic state that Freud was exploring exhibited lost connections to something important to the extent that the depressed individuals became so identified with this lost object that they kept it firmly within themselves. They were unable to establish a meaningful connection or part from it and grieve its loss. Sadness became inseparable from their condition.

In sadness, one knows what they have lost, but in depression, the loss is often indiscernible and can't be addressed consciously. It is often interpreted by the individual as a sign of their own inadequacy, unlovability, or damage. They feel rejected, abandoned, and angry toward themselves in the form of shame, self-criticism, and guilt that their "badness" might have driven this thing away from their life. Thus, they feel inherently corrupt.

There Is a Lot of Further Research Connecting Depression With Anger.

Friedman, A. S. (1970) found that individuals diagnosed with depression scaled higher on the Resentment subscale of the Buss-Durkee Inventory than non-depressed people. Resentment is defined here as "repressing the experience of the hostile affect from consciousness" (4). Subjects reported significantly less verbal open hostility but significantly more resentment. Becker & Lesiak (1977) found that in clinic outpatients, the severity of depression correlated with covert hostility, including guilt, resentment, irritability, and suspicion, but not with overt hostility.

In earlier research by Friedman et al. (10), people were asked if it is ever right to be angry. Hospitalized depressed patients answered "yes" significantly less often than non-depressed control subjects. This suggests difficulty with acceptance and expression of anger or aggression at the time of depression. Riley et al. (1989) concluded in their study that "the results […] generally support the hypothesis that depression is related to an inhibition in anger expression. The depressed group reported higher levels of anger suppression than either the normal or PTSD groups" (11).

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In another study by Kellner, R., Hernandez, J., & Pathak, D. (1992), 100 participants diagnosed with depression were given an extensive questionnaire about their condition. In all four groups, depression predicted inhibited anger for both sexes.

Improvement in all domains of inwardly directed hostility has been reported with the alleviation of depression (Blackburn et al. 1979; Mayo 1978; Friedman 1970).

Goldman & Haaga (1995) connected both anger and fear in depression. In comparison to non-depressed subjects, depressed subjects express more anger toward close family members than to others. This finding seems plausible considering the high rates of marital conflicts in couples that include a depressed partner (Schmaling and Jacobson, 1990). The fear of expressing anger to other people was highly correlated with anger suppression because of the fear of the consequences of such expression.

Brody et al. (1999) demonstrated that, in comparison to the never-depressed control group, recovered depressed patients reported suppressing their anger and being afraid of expressing it because they viewed it as damaging toward other people. The authors hypothesized that anger inhibition may play a causal role in the recurrence of depression.

These findings link both anger and the fear of expressing it, causing depressed individuals to suppress their anger out of fear. Thus, the role of inhibited anger in depressive conditions seems to be crucial.

There might also be confusion when we describe sadness as opposed to anger. Castel, P.-H. (2016) indicates confusion between these notions:

The very fact of saying "You make me sad" to somebody often expresses not so much sadness as anger and resentment. From a more psychological standpoint, sadness is often consciously experienced as an inward rage barred from public display; anger, similarly, when not fully acted out, commonly reverts to grief and feelings of helplessness. The opposition of inward vs. outward feelings will often reflect socially coded constraints on the legitimacy of the public exhibition of affective states. Agitated and violent children may actually be sad, while passive or submissive women are internally consummated with rage. (2).

Researchers such as Arieti, Bemporad, and Bowlby view depression as a sadness that cannot be "metabolized," so the work of sorrow cannot be completed. Inhibited anger, fear of expressing it, and lack of knowledge or positive previous experience on how to express anger constructively might play a crucial role in hindering the process of sorrow to eventually be rid of sadness and the symptoms of depression.

When dealing with depression both on a personal and therapeutic level, we need to take into account the possible presence of suppressed anger and equip ourselves and our clients with tools to deal with and express it constructively. Nancy McWilliams (2011) suggests that depressed individuals be in long-term or open-ended therapy instead of a pre-set number of sessions. If they have sufficient time to recognize their anger in a therapeutic environment, they will be able to address it. McWilliams states:

Treatments that are arbitrarily limited to a certain number of sessions may provide welcome comfort during a painful episode of clinical depression, but the time-limited experience may be ultimately assimilated unconsciously by the depressive person as another relationship that was traumatically cut short—further evidence that the patient is a failure in maintaining attachments (7).

Recognizing inhibited anger in a depressive state, learning to express it constructively in a therapeutic environment, and addressing the fear of losing important relationships due to anger can be salubrious strategies in helping one alleviate the symptoms of depression.