- Common life experiences can overwhelm our ability to cope.
- Experiences like divorce, infertility, or unemployment can even precipitate psychiatric disorders.
- The emotional difficulty of such experiences is often overlooked.
In my psychiatric practice, I treated a young man who had, among other problems, very severe acne. He told me a story about when his dermatologist started him on a new treatment. My patient asked the doctor how long it would be before there might be results. The dermatologist replied, “It depends on your emotional state.” Something inside the young man leapt with excitement, as he thought he might finally have the chance to talk about his chronic anxiety. But the dermatologist simply concluded the appointment and told him to return in a month.
This patient did well in treatment with me. In a couple of months his mood, anxiety, and even acne greatly improved. Sadly, he had endured 10 years of anxiety and depression before finally getting the treatment he needed. These delays are often par for the course when it comes to appropriately treating common life problems, which have understandable, and even severe, emotional consequences.
Mental health problems are usually thought of as coming from one of two places. Either you’ve had a troubled upbringing or you have bad genes. Both are, in a sense, bad luck and thus assumed to be uncommon. But are these two pathways really the main routes to emotional problems? In fact, there are many ordinary life circumstances that bring with them formidable emotional issues. Enduring those necessary chapters of life can even tip the balance and bring about a psychiatric disorder. But because they begin with common life experiences, they are often disregarded as nothing more than part of life.
I’m referring to life experiences we consider normal, in the sense that they happen, expectedly, to many, if not most, people. Many reliably lead to emotional difficulties that will fester without some kind of assistance. Naming and understanding these experiences can go a long way to supporting those who suffer because of them.
The four common occurrences I most often see people struggle with are major medical illness, infertility and miscarriage, divorce, and unemployment. Each is a major life event that in many cases also becomes an emotional crisis. I can testify after 30 years as a community psychiatrist, that most of these are not referred for psychological treatment. What follows is a quick tour of these otherwise frequent events and a look at what needs to change to make them less difficult for all involved.
Major Medical Illness
This year alone, 1.8 million people will be diagnosed with cancer. No one will be surprised to learn that distress, anxiety, and depression often follow such news. These states will evolve throughout the treatment cycle; some will improve, others will worsen. Families will also struggle. Unfortunately, identification of emotional problems and offers of help often do not fit in with usual care. Patients and family members are infrequently monitored for depression. Before a major cancer center opened near my office, I only received referrals from oncologists when a patient was difficult to deal with.
In academic medical centers, there have been studies, and there are now standing programs, for taking care of the emotional needs of cancer patients. They are excellent. I mention them to acknowledge that efforts are underway to improve mental health in oncology patients, but also to show that this enormous lack of attention is not due to a lack of knowledge or experience. It is due to the lack of acknowledgment of the psychological aspects of medical illness.
This year, roughly 800,000 Americans will have a heart attack. It is now widely understood that depression, especially in men, is a common occurrence after a heart attack. Furthermore, patients with post-MI (myocardial infarction or heart attack) depression have a far worse cardiac prognosis. I found only two major studies attempting to treat post-MI depression. The most well-known study used an average of 68 mg of sertraline (Zoloft). My starting dose for an adult is 100 mg in almost all cases. Under-treating medical patients with psychiatric medication is common and unnecessary. Modern psychiatric medicines are well-tolerated by medically ill patients in adequate doses.
Smaller studies now strongly suggest that not only can you treat depression in these patients, but that the increased risks of cardiac complications and even death lessen as does the depression. A similar relationship is true with depression after stroke (patients do better in rehabilitation and regain more function when treated successfully for depression). In fact, scientists now know that the relationship between depression and vascular disease (heart attack and stroke or diseases of blood vessels) is “bidirectional.” In other words, depression accelerates the development of vascular disease, and vascular disease exacerbates depression. Yet, research on treatment is limited and referrals for care remain infrequent.
Infertility and Miscarriage
Most people know couples who have gone through the trying experience of losing a pregnancy or being unable to conceive. The grief weighs heavily on young couples and particularly on potential mothers. The sense of isolation, loss (especially in the case of miscarriage), and even shame are pronounced. When a pregnant person has a miscarriage, they can feel a sense of grief, similar to when a loved one dies. But there is no wake or ritual to mark the passing and gather support. The entire process is usually quite private and lonely. Marital discord and depression are common consequences; the burden is simply too heavy for one person or small family to bear.
Divorce is listed in most psychology textbooks as the second-most-stressful common life event, just behind the death of a spouse. When I began my psychiatry practice, I wished my training had included a course on divorce, as many people came to my office mid-divorce as the stress, anxiety, and anger they felt became unmanageable. The divorce rate in the U.S. still hovers between 40 percent and 50 percent, yet it is sadly rare for people in the process of divorce to be educated on the emotional consequences they may suffer, or where to seek help.
At its lowest point this year, joblessness was at 5%. Although low in economic terms, that still meant many people were struggling to make ends meet. When you apply for unemployment insurance, you are required to show that you have been job searching, and to sit through classes on jobs and interviews. There is no mention of the well-documented stress and emotional toll that comes with being unemployed. Money equals survival in our society. It is also associated with prestige and self-worth. Adding depression screening and brief counseling to the unemployment application process could help many face this difficult life chapter more effectively.
I’ve chosen four common life experiences from both my practice and psychiatric studies, which reliably carry a host of negative emotional consequences. Obviously, life presents all manner of difficult episodes. But there are some events that can overpower many people’s coping abilities. The end result is emotional turmoil. For those with even the slightest vulnerability to mental disorders, this descent may tip the balance toward becoming psychiatrically symptomatic.
Sadly, our society still treats these experiences as if they were just another bad day—yet another sign that we have a long way to go when it comes to removing our discomfort with discussing painful emotions and the commonality of mental illness.
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