The terms depression and sadness are often used interchangeably, which I believe is an error. Sadness is generally experienced when there is a loss of something or someone who is held dear, but is not accompanied by feelings or hopelessness, helplessness, despair, guilt, or loss of self-esteem or self respect. Depression on the other hand is accompanied by a loss of self esteem, often accompanied by hopelessness, despair, helplessness and/or guilt. Clearly, only depression involves a loss of self-esteem.

When performing a psychiatric evaluation of impaired mood, i.e., “sadness” or “depression,” it is necessary to distinguish one from the other. For forensic assessments, it is necessary to be able to identify causation, whether or not the causation was proximate and substantial, the occurrence of emotional distress, what will be necessary in order for a resolution to occur, and prognosis. Contained within the prognostication is the acknowledgment that not all resolutions are complete and that the outcome depends on the injured party’s ability to self-reflect, comply with treatment, and be willing to acknowledge the existence of the loss. Prognosis assists a forensic economist to compute monetary damages.

Differentiating depression from sadness is diagnostically important because in the instance of sadness, the sad person’s core identity is whole or intact as far as his/her self-image is concerned. The loss could be the death of a loved one, the destruction of a home or livelihood. If the loss is of an emotional attachment to what is lost, then severing of the emotional attachment is painful and wound-like, but the person’s coping mechanisms remain fundamentally intact or at least as intact as they were prior to the loss, but there is no loss of self-esteem.

Sometimes a person who has “lost” beloved person has preexisting conflicts about the attachment. For example, the loss of a partner during a separation or divorce. The loss may be tied to feelings of guilt.

The emotional reaction to the loss may rise to the level of a psychiatric diagnosis of depression which is relevant to establish if “emotional distress” actually exists. Some other examples, and explanations, for a triggering event and how it plays out or evolves are given below. By describing the dynamics of loss, I hope attorneys will better understand the psychiatric mechanisms in play.

Example 1. In some romantic relationships, the partner is over-idealized which enables a person to inflate his own self-esteem. This creates a sense of security and contentment, a feeling of fullness or satisfaction, by borrowing self-worth-by-association but also a vulnerability to loss. If the romantic relationship ruptures or otherwise ends (e.g. by a break-up, divorce, disgrace, physical impairment, or even death), then the prior contented feeling may be replaced with feelings of abandonment, sorrow, anger at being abandoned, emptiness, self doubt, irritability, and, often, a frantic effort to reestablish an attachment with the lost person or a substitute, i.e., a rebound romance. The loss creates emotional distress.

Example 2. A psychiatrist can assess whether depressed feelings have contributed to a clinical neurobiological Depression or remain in the realm of a normal grieving process. Psychobiological depression is commonly thought to be a necessary component for Bipolar Disorder (formerly called manic depressive illness), which is itself due to a genetic predisposition or vulnerability, or some Major Depressive episode. Bipolar Disorder is usually episodic, and may or may not be triggered by external events. The depressive affect causes serious changes in emotion, which are characterized by feelings of being sad, gloomy, blue, down in the dumps, irritable, disinterested in pleasurable activities, having a disturbance of sleep, excessive worry, excessive irrational guilt, diminished self-worth, loss of interest in personal hygiene, social reclusiveness, and feelings of suicide, or rarely homicide, due to feelings of emotional pain and irrational guilt. It is necessary to determine if a life event triggered the neurobiological depression, because in litigation, a pre-existing condition is sometimes “blamed” for emotional distresswithout factoring in how the damage escalated or set off the depressive disorder and its consequences.

If the sequence is that depression occurs before the alleged offending event, then a more primary internal pathogenic process should be suspected, i.e., a psychobiological organic alteration of normal brain chemistry functioning. The forensic psychiatrist considers multiple sources of information in order to understand and use his experience and training to explain the relevance of the sequence to a layperson, such as a juror or arbitrator.

Not surprisingly, in specific instances, events are more complicated than simple cause and effect. It is well known and generally accepted that a person may have a Bipolar Disorder triggered following the loss of an important person such as the death of a parent, or the loss of an occupation which is tied to the litigant’s self-esteem.

Example 3. The loss of a partner, or a parent. It may happen that the loss of other important anchors in the person’s life may trigger a permanent change in the way the person’s immune system functions. Environmental triggers of emotional loss causing subsequent permanent biologic/organic pathology are well known in other areas of medicine, such as the onset of autoimmune disorders (Type 1 Diabetes Melletus and Hashimoto’s Thyroiditis, for example), which thereafter persist.

Some children develop Type 1 Diabetes after the loss of a parent. Thereafter, the Type 1 Diabetes is permanent even if the child is reunited with the parent.

An example of a primary depression which is not related to an inherited disorder of brain chemistry, would be the product of guilt which arises as the result of an act by the individual, be it intentional or unintentional. An example of an intentional act leading to guilt would be the conscious breaking of a vow such as a marital vow, when the person has an affair. An example of an unintentional source of guilt would be of a person accidentally striking a pedestrian causing that person to be injured or die. In each of these examples, the guilt, which is a function of a person’s conscience, leads to self-punishment, self-criticism, internalized feelings of disgust, and internalized self-anger, all of which cause the person to see him or herself as not being the “good person” he/she had formerly held himself out to be. As a result, self-esteem and self-respect diminishes and the person experiences the loss of that self-esteem as a clinical Depression (i.e. a diagnosed medical disorder).

Each person who struggles to resolve a traumatic experience may manifest it differently. The process of resolution determines the severity, diagnosis and prognosis which a jury must understand in order to make an informed decision about claimed emotional distress.

In some instances, a person who is victimized by another person may himself become depressed. This depression may have several causes. One possible cause is the victim was living in denial about certain risks. After the event, the victim castigates himself for not being smarter, wiser, more vigilant, stronger, or otherwise better able to anticipate the offending event which occurred. There may be a belief that “nothing bad can happen to me even though it happens to others,” which is then punctured when the bad event occurs to the person. This loss of grandiose self-image may be experienced as depression.

A corollary issue is the emotional effect the event had on the defendant. Did the defendant suffer a loss of self-esteem for harming the plaintiff?

Another example occurs when a person is injured due to circumstances beyond his control and which is unanticipated, but nevertheless leads to a disability, which results in hardship to the person or people who the person loves. For example, the truck driver whose accident prevents future employment, results in the truck driver feeling his family cannot be supported. This causing of hardship to others becomes a source of guilt, which is irrational but nevertheless deeply felt, i.e., the person’s injury is not his fault, but nevertheless he assumes responsibility for the consequences to others from his injury.

A third example occurs when an injury which causes a psychiatric disturbance to the person, such as a depression, leads to disrupted interpersonal relationships, which may then lead to the end of a marriage or other relationships. This creates guilt and/or anger, both at the cause of the injury as well as the person’s self-criticism at not being able to cope with the effects of the injury, which then leads to depression because the person has lost control of his emotions, the consequences of those emotions, and, thus, his self-esteem and self-respect.

The prognosis for depression is worse than the prognosis for sadness. When rendering a medical opinion, my extensive experience and training with the dynamics of depression assist me in conducting my examination and explaining my findings to a jury. The dynamics are recognized, established and documented in assessing if and how Depression may have developed.