A vigail didn’t have a debilitating drug or alcohol problem. She didn’t have schizophrenia, OCD, bipolar disorder, or any other pathological psychiatric condition either. The banks weren’t about to foreclose on her mortgage and neither she nor her husband were seriously ill. In fact, you’d figure she was basically sane as could be and one of the last people in the community who’d be coming into my office for a psychiatric evaluation.

Nevertheless, here was Avigail, sitting in the comfortable chair by the window and telling me how depressed she was. She had a daughter who was “a bit too modern” for her liking, a married son who lived too far away, and one of her younger children took Ritalin for ADHD. Her job as a math teacher at Bais Yaakov wasn’t as exciting as she’d thought it would be when she switched over from the public school system, and her husband’s 401(k) had lost 6 percent last year instead of maintaining its historical steady growth.

“It’s like a cloud of darkness,” she said. Clearly, there was real pain here. “Plain and simple, I’m depressed,” she said with candor. “I think I need medication. I have a friend who takes Prozac or Paxil or Zoloft or one of those things. Maybe I should try it too.”

I admired her for taking responsibility for her mental health — most people facing those feelings of gloom tend to just trudge through the fog without seeking assistance that could be quite beneficial.

But as she answered my questions and filled out the bigger picture, I realized that Avigail lacked the fundamental symptoms of major depressive disorder. She was generally healthy and without any of the symptoms that would suggest a neurological or medical condition to explain her mood. There was no family history of depression and no prior history of psychiatric treatment, no major financial or legal problems, and no trauma history or hidden pill issue.

Baruch Hashem, she wasn’t suicidal or hopeless and she still enjoyed many meaningful activities. She didn’t suffer any major disruption of her sleep or appetite and she was still functioning at work and at home.

While Avigail was definitely feeling down and depressed, she wasn’t experiencing an episode of major depressive disorder that would warrant medical treatment or medication to correct any chemical imbalance.

I knew that she was frustrated. I believed her when she said that most days she felt hopeless and discouraged, how she wallowed in feelings of wishing life was better. Still, this wasn’t a biological depression with the kind of profound dysfunction that would require intensive psychiatric treatment.

Sometimes when people hear this kind of assessment, they get defensive and end up feeling embarrassed or angry. I had to be careful to make sure that she was going to feel heard and supported.

“Avigail, I know how hard it is when you’re feeling down, but there is a difference between major depressive disorder and going through a rough patch.”

“You think I’m just making up the way that I feel?”

“Of course not,” I responded, because I really didn’t. “But there is a difference between feeling down and having a chemical imbalance that will respond to medications. You’ve got some tough things going on in your life but, thank G-d, your body and brain are in good shape. It’s important to know that every medication has its risks and benefits and, in your case, I’m not sure there would be any significant benefit.”

“Why are you saying that, Dr. Freedman?”

“Because the people that benefit the most from medications are the ones who are suffering the most. People with a change in their appetite, their sleep, and those who don’t have any energy. People who are crying all day long. Those are the folks who benefit the most from antidepressants.”

“So if there isn’t a magic pill for this, then why do so many people take antidepressants when they’re feeling down?”

“Certainly, there are a lot of people who benefit from antidepressants — but it’s a question of using them at the right time and when they’re indicated.”

“Wait, are all my friends who take the stuff putting themselves in danger?”

“Not necessarily. Most antidepressants are pretty safe medications,” I responded. “It’s about ensuring that there is a proper indication for taking them.”

“Then why do so many doctors prescribe them? Why are psychiatrists notorious for this?”

“I’d ask the same thing about scratch tickets and why so many people buy them if it’s an awful idea… but to be serious, that’s a longer and more complicated discussion. You should know that most antidepressants are prescribed by primary care doctors, not by psychiatrists.”

“Okay.” She took a deep breath. “So if I don’t pop a pill, then what am I left with? How do I start feeling better?”

“Well, for starters, you can exercise, you can eat healthy, you can work on being grateful, and you can reach out for support. I have the name of a great therapist if you’d like to meet her.”

“I’m not sure.… I’ll take the card but I’m not sure if I’ll call her.”

I smiled and handed her my colleague’s card. “I’m not in the business of forcing folks to do stuff they’re not interested in doing.”

Avigail took the card and sat back in her seat. “You know, everyone else’s life seems so easy. Their jobs, their husbands, their kids… It all seems so much easier than mine. I have so many tough things in my life.”

“You’ve got to try and follow what our rabbis say in Pirkei Avos. You need to be samei’ach b’chelko.”

“Easier said than done.”

“Exactly! That’s why you need to work on it. Listen, the best therapist I know wasn’t one of these ‘world’s experts’ at Harvard Medical whose lectures I was forced to sit through, it was my rosh kollel in Boston, Rabbi Naftoly Bier. He used to tell us to take a notebook and to write at least three things each day that made us happy and grateful. ‘Watermelon is back in season.’ ‘My legs are healthy so I can walk to shul.’ ‘My kids are reading nicely together on the couch.’ Things like that. It really helps to keep everything in perspective.”

“How is that going to help?”

“He called it the ‘Gratefulness Diary,’ and when you actually work hard to do it right, you’ll have close to 100 good things to be happy about at the end of a month, and those are just the ones you’ve listed. Training yourself to be grateful and positive facilitates serious personal growth and doesn’t leave too much time for being frustrated or upset.”

“Sounds a bit like Breslov, no? Maybe not for the mainstream crowd?”

She was right, but Rabbi Bier was a serious Yekkeh who even kept the old German minhag of washing before Kiddush. “You’d think so but no. I’m telling you that a Gratefulness Diary is a good place to start.”

“Okay,” said Avigail. “I guess I’m all set then, and I’m not crazy — which is good news, right?”

“Absolutely,” I told her as I walked her to the door. “Put it down as the first thing in your Gratefulness Diary.”

Rabbi Bier would have been proud.

Originally featured in Mishpacha, Issue 667. Jacob L. Freedman is a psychiatrist and business consultant based in Jerusalem. He serves as the medical director of services for English-speakers at Bayit Cham, a national leader providing mental health treatment and outreach within the religious community. Dr. Freedman can be reached most easily through his website www.drjacoblfreedman.com.