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Depressive Disorders

Depressive Disorders

Depression as a normal emotion

Depression as an abnormal emotion

Clinical pictures of depressions

Psychodynamic mechanisms of depression

Sociocultural factors in depressions

Treatment of depressions

BIBLIOGRAPHY

The term “depressive disorders” refers to a large group of psychiatric conditions whose main characteristic is an abnormal feeling of depression. This classification is broad as well as vague; it implies a definition of depression and of abnormal depression. Moreover, the word “depression” refers sometimes to an ordinary emotion, at other times to a symptom, and still at other times to a given clinical entity.

This article will discuss depression as a normal and as an abnormal emotion, clinical pictures of depressions, psychodynamic and sociocultural aspects of depression, and treatment.

Depression as a normal emotion

Depression is a common emotion, second only to anxiety in psychiatric concern and study. Often depression is referred to by such terms as sadness, melancholy, despondency, dejection, low spirit, and anguish. Although practically all human beings have at some time experienced depression, this emotional state is among the most difficult to describe and to analyze. It is a pervading feeling of unpleasantness accompanied by such somatic conditions as numbness, paresthesias of the skin, alterations of muscle tone, and decreases in respiration, pulsation, and perspiration. The head of the depressed person has the tendency to bend; the legs flex; the trunk tilts forward. The face assumes a special expression because of increased wrinkles and decreased mimic play. There is also retardation of movements, rigidity in thinking, and a general feeling of weakness.

It is, however, at the mental rather than the somatic level that depression has more specific characteristics. Whereas anxiety is characterized by an expectancy of danger, depression is accompanied by a feeling that the dangerous event has already occurred, that the loss has already been sustained. For instance, the loved person has already died, the good position has been lost, the business venture has failed, a self-concept or an ideal can no longer be maintained. There is also a more or less marked sense of despair, of unpleasant finality, as the lost object is considered irreplaceable. The loss is deemed to have repercussions on the present as well as the future. From these examples it is evident that, at least in conditions considered normal, depression seems to be a reaction to psychological processes, such as evaluations and appraisals, that have occurred at a cognitive level. The person who becomes depressed must have been able to understand and to assess the significance of certain events. Thus, cognitive and, as we shall see later in detail, social factors (inasmuch as the latter enter into complicated cognitive processes) are very important in the engendering of depression.

Such considerations would make depression a uniquely human emotion, different from more primitive emotions such as fear, rage, and some forms of anxiety that occur also in much lower animals. This point, of course, is debatable. Inasmuch as animals cannot verbalize their feelings, it is an open question whether or not the belief that animals become depressed is an anthropomorphization. A dog, for instance, may appear depressed when his master is away, but it is doubtful that this is either a feeling involving the future or a sense of loss that transcends the immediate discomfort. A feeling of deprivation rather than despair seems to be involved here. On the other hand, these uncomfortable feelings of deprivation, which even infrahuman animals are capable of experiencing, may be the precursors of human depression.

According to Arieti (1959a), depression may have functional significance. If depression had negative survival value, species capable of experiencing it probably would not have procreated themselves in the course of evolution. Other emotions have survival value; anxiety, for instance, is a warning of forthcoming danger. As with other unpleasant sensations and emotions, the function of depression is to urge the person who experiences it to alter his behavior, so that the factor engendering depression will disappear or be removed.

For example, an individual hears the news of the unexpected death of a person he loved. After he has understood and almost instantaneously evaluated what that death means to him, he experiences shock, then sadness. For a few days all thoughts connected with the deceased person will bring about a painful, almost unbearable feeling. Any group of thoughts even remotely connected with the dead person will elicit depression. The individual cannot adjust to the idea that the loved person does not live any more. And, since that person was so important to him, many of his thoughts or actions will be directly or indirectly connected with the dead person and therefore will elicit sad reactions.

Nevertheless, after a certain period of time, that individual adjusts to the idea that the person is dead. By being unpleasant, the depression seems to have a function—its own elimination. It will be removed only if the individual is forced to reorganize his thinking, to search for new ideas so that he can rearrange his life. He must rearrange especially those ideas that are connected with the departed, so that the departed will no longer be considered indispensable.

Depression as an abnormal emotion

Depression is deemed abnormal when it is excessive relative to the antecedent event or events that have elicited it; when it is inappropriate in relation to its known cause or precipitating factor; when it is a substitution for a more appropriate emotion, for instance, when it takes the place of hostility or anxiety; or, when it does not seem to have been caused by any antecedent factor of which the person is aware.

Both constitutional and psychological factors have been postulated to explain the occurrence of abnormal depressions. The constitutional factors have been studied particularly in connection with the depression that occurs in the course of manicdepressive psychosis. Slater (1936), for instance, believes that the inheritance of manic-depressive psychosis depends on a single dominant autosomal gene. To explain why the incidence of the psychosis is lower than would be expected from his hypothesis, he states that the dominant gene is a rare one. Kraines (1957) believes that the depression, as well as the manic state of manic-depressive psychosis, is due to a dysfunction (either increased or decreased function) of the diencephalon. Accordingly, the experience of depression is a “psychic response” to this diencephalic dysfunction. Elevated values for adrenal and thyroid functions, blood pressure, and pulse rate are reported frequently in depressed patients (Reiss 1954).

Arieti (1959a) has described what happens when the process of reorganizing ideas concomitant with normal depression fails. In such cases, depression, rather than forcing a reorganization of ideas, slows the thought processes that are carriers of mental pain. There appears to be a teleological or adaptational mechanism that seemingly acts with the goal of decreasing the quantity of thoughts in order to decrease the quantity of suffering. At times, the attempt to slow thought processes succeeds so well (as in the state called “stupor”) that only a few thoughts of a general and vague nature remain. These are accompanied by an overpowering feeling of melancholy. Thus, the slowing down of thought processes that have an unpleasant emotional tone is a self-defeating mechanism and, in a vicious circle, aggravates the situation instead of alleviating it.

Often, abnormal depression defensively replaces seemingly more appropriate emotions, generally anxiety or hostility. The patient appears to be more capable of coping with a feeling of depression than with anxiety or hostility.

Clinical pictures of depressions

Depressive disorders have been known since ancient times. Some of the great physicians of antiquity, like Hippocrates and Aretaeus, wrote about the conditions that are now called “psychotic depressions.” In spite of this long record in the history of medicine, no agreement has been reached about the various classifications of depressions or the nature of the various types. Following is a brief account of the different clinical pictures that have been recognized.

Reactive or psychoneurotic depression

Reactive or psychoneurotic depressions are characterized by relatively mild feelings of despondency, guilt, and self-depreciation; mild retardation and reduction of spontaneity; and the absence of hypochondrial preoccupations. These depressions seem to occur subsequent to, or as a reaction to, an unpleasant or tragic event in the life of the patient. The patient is aware of this connection. Some authors emphasize the fact that reactive depressions are not endogenous, that is, are not engendered by internal factors, such as organic or hereditary predispositions, but are consequent to external factors. In addition, the patient does not accept the depression as a way of living and, like all other psychoneurotic patients, would like to be relieved of his depressed condition.

Depressed type of manic–depressive psychosis

The depressive aspect of manic–depressive psychosis has generally received the most consideration. Although it was already recognized by Aretaeus, it was described more fully and clarified in some aspects by Kraepelin in the sixth edition of his Psychiatrie: Lehrbuch für Studierende und Ärzte, published in 1899 (see Kraepelin 1883).

This type of depression is characterized by a triad of symptoms: a pervading feeling of melancholia, disordered thought processes characterized by retardation and unusual content, and psycho-motor retardation. In addition, there are, less typically and less frequently, some somatic dysfunctions.

This type of depression occurs much more frequently in women than in men. In the majority of cases it is periodic, not permanent. Attacks of depression are separated by normal intervals.

Feeling of melancholia. The onset of the pervading feeling of melancholia is sometimes quite acute and dramatic, at other times slow and insidious. At times, it is misunderstood or unrecognized at first. When an unpleasant event, such as the death of a close relative, has occurred, a certain amount of depression is justified. However, when a certain period of time has elapsed and the depression normally should have subsided, it becomes instead more intense. The patient has an unhappy, sad appearance. He looks older than his age, his forehead is wrinkled, and his face, although undergoing very little mimic play, reveals a despondent mood. In some cases the main fold of the upper eyelid at the edge of its inner third is contracted upward and a little backward (sign of Veraguth).

The patient is often unable to describe his feeling of intense unhappiness. He may say that “his eyes have consumed all the tears” and “his life is a torment.” He experiences a desire to punish himself by destroying himself and, at the same time, to end his suffering. Suicidal ideas occur in about 75 per cent of patients, and actual suicide attempts are made by at least 10 to 15 per cent.

Disordered thought processes. The second important symptom concerns the content and type of thinking. Gloomy, morbid ideas leave little room for other thoughts. The patient convinces himself that he is hopeless; he has lost or will lose all his money, his family is in extreme poverty, he is incapable of working or even taking care of himself. There is no great variety in his thoughts. He gives the impression of selecting thoughts that have an unpleasant content so that his melancholic mood is retained. Quasi-delusional ideas or definite delusions may occur, often representing distortions of the body-image and hypochondriasis. The patient thinks, for example, that he has a tumor, syphilis, or tuberculosis, that he has lost his bowels, or that his brain is melting. The patient is often self-accusatory, in a delusional form. He believes that he has committed many crimes or that some crimes which have been committed by others are, indirectly, his responsibility. Especially in some Western subcultures that are permeated by intense religiosity, the ideas of guilt, sin, self-condemnation, and eternal damnation are prevalent. Hallucinations are rare in this condition and occur almost exclusively at night.

Psychomotor retardation. The third important sign of depression is retarded hypoactivity. The actions of the patient are reduced in number and are carried out at a slow pace. Talking is reduced to a minimum. Employment and household responsibilities are ignored, and appearances are neglected. When depression reaches a state of stupor, the patient cannot talk or move at all and may be mistaken for a catatonic patient.

Somatic dysfunctions. Frequent accessory symptoms are reduction in sleep, decrease in appetite, loss in weight, marked decrease in sexual desire, dryness of the mouth caused by decreased secretion of the parotid glands. A frequent subvariety of this condition, called “agitated depression,” is characterized by motor restlessness rather than hypoactivity.

Manic episodes. Kraepelin emphasized that in many patients attacks of depression alternate with, or occasionally are followed by, other attacks that seem to have contrasting characteristics. These are the manic attacks, characterized by a state of elation or euphoria, a disorder of thought processes distinguished by flight of ideas and pleasant content, and an increased mobility. Kraepelin thought that when the illness manifests itself in a complete form, both the depressed and manic attacks occur, although in different sequences. Thus he conceived both forms of attack as part of a specific clinical entity, to which he gave the name “manic–depressive psychosis.”

It was soon noticed that the manic attacks are much less frequent than the depressive ones. Perhaps the difference in frequency is not as marked as it seems. It could be, in fact, that mild attacks of mania are better tolerated or unrecognized by the patient or his relatives.

The intensity of the depression is not the only characteristic differentiating between psychotic and reactive depression. In a psychotic depression the patient accepts his depression as his way of life and feels justified in feeling as he does.

Psychotic depressions

Many depressions, even of psychotic proportions, are never preceded or followed by manic attacks. Many authors are reluctant to include such depressions in the manic–depressive syndrome. They feel that these depressions probably should have a classification unrelated to the Kraepelinian psychosis.

Except for the fact that it is not followed by manic attacks, psychotic depression is no different from the depression of the manic–depressive psychosis.

Involutional melancholia

Involutional melancholia (involutional psychosis, melancholic type) occurs in women at least three times as frequently as in men and is characterized by an intense feeling of depression that occurs around the “involutional” age. In women this age generally coincides with the menopause. However, involutional melancholia may precede or follow the menopause even by an interval of four to five years.

Involutional melancholia presents the same characteristics as the depression of the manic–depressive psychosis, with the following exceptions: (1) agitation and restlessness often substitute for, or are superimposed on, the hypoactivity, and (2) the prepsychotic personality differs from that of the manic–depressive. The patient is described as a quiet, retiring, worrisome, frugal, and rigid individual.

Kraepelin, who had originally excluded involutional melancholia from the manic–depressive category, reconsidered his views and finally included it in that group. Kraepelin thought that involutional melancholia had an unfavorable prognosis. However, as some of his contemporaries showed, this is not so. Electric shock treatment, devised by Ugo Cerletti and Lucio Bini in 1938 (Cerletti 1950), seems to be able to cure practically all cases, if by cure we mean a return to the prepsychotic level of adjustment, whatever it was.

Other types of depression

Depressions may also occur as parts of other syndromes or conditions. A depression occurring in old age is often referred to as “senile depression,” and one occurring in schizophrenia as “schizophrenic depression.” When a combination of schizophrenic and manic–depressive features occurs, the syndrome is often called “schizo–affective psychosis.”

A type of depression that is often described in the French and Italian literatures is the one called “Cotard’s syndrome,” after the neurologist J. Cotard, who first described it. Cotard’s syndrome is characterized by a depression accompanied by a delusional state of negation. Nothing exists; the world has disappeared. After the cosmic reality is denied, the physical reality of the patient himself is denied.

Spitz (1946) has described what he calls “anaclitical depression” in infants who have been separated from their mothers between the sixth and eighth months for an approximate period of three months. This type of depression seems more similar to a state or sense of deprivation, as it occurs in infrahuman animals, than to an emotional state that includes a sense of finality and despair.

Psychodynamic mechanisms of depression

Many authors feel that even if constitutional-hereditary facts are important in the etiology of depressive disorders, some experiential factors oc-curing in the early life of the patient have started psychodynamic patterns that have finally determined these conditions. Psychoanalytic studies have contributed greatly to the psychodynamic understanding of depressions. These psychodynamic mechanisms apply primarily to the depressions labeled as the depressed type of manic–depressive psychosis, psychotic depression, and involutional melancholia. It was Freud’s pupil Abraham (1912), not Freud, who introduced manic–depressive psychosis to psychoanalytic conceptions through a comparison of abnormal depression with normal grief. Both conditions are at times elicited by a loss that the person has suffered; but, whereas the normal mourner is concerned about the lost person, the depressed patient is disturbed by guilt feelings. The unconscious hostility that he had for the lost object is now directed toward himself. Abraham also assumed a regression to an ambivalent pregenital stage of object-relationship, that is, a return to an anal-sadistic stage.

Freud (1917) accepted Abraham’s idea that there is a relation between mourning and melancholia and pointed out that whereas in mourning the object was lost because of death, in melancholia there was an internal loss because the lost person had been incorporated (or introjected). The sadism present in the ambivalent relationship is then directed against the incorporated love-object.

Radó (1928) suggested that melancholia represents a desperate search for love. The ego tries to punish itself in order to prevent parental punishment.

According to Melanie Klein (1948), a “depressive position” is a normal event in the life of every child, generally at the time of weaning, that is, around the age of six months. The mother who before was seen by the child as two persons (one good and one bad), according to Klein, is at this time seen as one person; the mother continues, however, to be internalized as a good or bad object. The child is afraid that his instinctual aggressive impulses will destroy the good object, and he interprets the loss of his mother’s breast and milk at the time of weaning as the result of the destructive impulses. The inability to solve adequately this “depressive position” may, according to Klein, lead later to a pathological depression.

Arieti (1959a) found the following mechanisms in the cases that came under his attention. Very early in the life of people who are prone to become psychotically depressed there is a period of intense gratification of needs. The mother or mother-substitute is motivated by a sense of duty to be as lavish as possible in her care and affection. This attitude predisposes the child to be very receptive to others, to introject the others, and later to be an extrovert and a conformist.

At a later period but still in early childhood, generally during the second or third year of life, although in some cases even much earlier, the family situation undergoes a drastic change. The mother now takes care of the child considerably less than before and makes many demands on him. This change in the mother’s attitude may be due to the fact that in the meantime another sibling has been born, and the mother is now lavishing her care on the newborn with the same duty-bound generosity that she previously had for the patient. More often, however, the reason for the change is to be found in the personality of the mother, who believes that when a child is an infant, he has to be fully taken care of, but as soon as he shows the first signs of an independent personality, he should start to be given increasing responsibilities, a sense of duty, of obligation, and the like. No transitional stages are allowed. The child who experiences a drastic change from an atmosphere of receptivity from the others to an atmosphere of expectation by the others may undergo a trauma. He tries to find solutions or pseudosolutions. Generally he adopts one of the two following mechanisms, which he will repeat throughout his adult life. The first is an attempt to make himself even more babyish, more dependent, and aggressively dependent, so that the mother, or the important adult who later takes her place symbolically, will be forced to re-establish an atmosphere of babyhood and of early bliss. Another mechanism consists in trying to live up to the expectations of the mother, no matter how high the price, how heavy the burden. Love or the early bliss will be recaptured only by complying and working hard. If love is not obtained, the patient is at fault; he must atone or work harder.

The patient finds out later in life that these mechanisms do not work. No matter how aggressively dependent the individual becomes, he does not recapture the early bliss. No matter how compliant and hard working he is, he does not obtain what he wants. This realization brings about the depressed feeling. The actual manifest symptomatology of depression occurs when a symbolic reproduction of the early trauma takes place later in life. A loss has been sustained and the patient feels that his way of living has caused such a loss. The loss may be the death of a person important to the patient, the realization by the patient that an important interpersonal relationship has failed (generally with the spouse), or a severe disappointment in a relationship to an institution or work to which the patient has devoted his whole life. At times the loss is more difficult to evaluate; it may concern such abstract concepts as ideals, re-evaluation of the meaning of one’s life, and personal significance.

Claiming and self-blaming depression

The psychological symptomatology of psychotic depressions has been divided by Arieti (1962) into two main types: the claiming depression and the self-blaming depression.

In the claiming depression, which has recently become more common at least in the United States, the symptomatology, although fundamentally one of depression, seems to be a gigantic claim. All the symptoms seem to have a message: “Help me; pity me. It is in your power to relieve me. If I suffer, it is because you don’t relieve me of this suffering.”

In the self-blaming type of depression the main emphasis is on self-accusation and self-depreciation. The patient feels he does not deserve help from others.

When the prepsychotic personality is of the aggressive–dependent type, the psychosis tends to be the claiming type of depression. When the prepsychotic personality is of the duty-bound, hard-worker type, the psychosis tends to be the self-blaming type.

The suicide attempt (often successful) made by patients affected by a psychotic depression has been the object of various psychodynamic interpretations. Several possibilities must be considered. (1) The suicide attempt may actually be a cry for help. The patient wants to convey this message to an important person in his life: “You have the power to prevent my death, if you wish to.” (2) The patient wants relief from suffering. (3) The patient wants to punish himself, since he feels guilt-ridden and deserving of drastic punishment. (4) The patient does not really want to kill himself but the detested person whom he has incorporated. The last explanation is the one originally proposed by Freud (1917) and the one still accepted by the orthodox psychoanalytic school. It is actually based on little clinical evidence and is not unanimously accepted by other schools.

Sociocultural factors in depressions

Sociological and cultural factors may be important in facilitating those conditions which predispose to depression, especially those of the manic–depressive type. Some psychiatrists (Bellak et al. 1952; Arieti 1959b) have noted a decline in incidence of this psychosis. For instance, in a period of 20 years (from 1928 to 1947), the percentage of first admissions to hospitals of manic–depressive psychosis in New York State was reduced from 13.5 per cent of all admissions to 3.8 per cent. Relevant information has been gathered in other parts of the world. Gold (1951) has found a relatively higher incidence of manic–depressive than of schizophrenic psychoses in the lands of the Mediterranean Basin, as well as in Ireland. He reports that in Oriental countries, especially where Hinduism and Buddhism prevail, manic–depressive psychosis is less common, but in Fiji manic–depressive patients are numerous. Gold writes further that whereas in India the incidence of manic–depressive psychosis is low and that of schizophrenia higher, the reverse is true for the Indians who have immigrated to Fiji.

Recently, however, psychiatrists have noticed, at least in the United States, an increase in the number of depressive disorders. This increase has not yet been subjected to statistical study and seems to involve depressions not typically of the manic–depressive category.

In his attempts to understand the decline of manic–depressive psychosis Arieti (1959a; 1959b) drew upon the concepts of the sociologist Riesman (1950). Manic–depressive psychosis occurs more frequently in those cultures which Riesman has called “inner-directed” and tends to disappear where this orientation is also disappearing. It is thus possible to formulate the hypothesis that an inner-directed culture evokes or increases the manic–depressive propensity.

Inner-directed society

In the inner-directed society the mother feels duty-bound and therefore at the time of the birth of the child is very much concerned with his care, permitting the child to develop strong introjective tendencies. Soon, however, the mother will start to burden the child with responsibilities and with a sense of duty and guilt. This is often made necessary by the fact that the mother now has to devote herself to another child. The bliss of paradise is lost, and life becomes a purgatory. An inner-directed personality develops in the sense that this orientation is implanted early in life by the direct and definite influence of the significant adults. Family-life and child-rearing practices are established that seem to correspond to those found in the families of manic–depressive patients.

This hypothesis, suggesting the influence of inner-directed society upon manic–depressive psychosis, receives some validation from the research of Eaton and Weil (1955) on the mental health of the Hutterites. The Hutterites are a group of people of German ancestry who have settled in the Dakotas, Montana, and the prairie provinces of Canada. The Hutterite society seems to be an inner–directed one. In a population of 8,542 people, Eaton and Weil found only 9 persons who sometime in their lives suffered from schizophrenia and 39 with mianic-depressive psychosis; that is, among the Hutterites manic—depressive psychosis occurred 4.33 times more frequently than schizophrenia, whereas in the general population of the United States the incidence of schizophrenia by far exceeds that of manic–depressive psychosis.

Treatment of depressions

Depressive disorders are generally treated with three types of therapy. (1) Psychotherapy (generally psychoanalytically oriented in the United States; in Europe, often existentially oriented) is generally administered to patients suffering from the reactive depressions, the various types of psychotic depressions provided they are of moderate intensity, and patients who are experiencing a symptom-free interval between psychotic attacks. (2) Drug therapy is employed in the treatment of moderately severe depressions. “Psychoanaleptic drugs,” such as imipramine hydrochloride, and the large group of monoamine oxidase inhibitors are among those used. (3) Electric shock therapy, commonly used prior to the advent of drug therapy, is now reserved for the most recalcitrant and stuporous cases. It is still the most frequently used treatment in involutional melancholia.

Silvano Arieti

[Other relevant material may be found inElectro-convulsive shock; Mental disorders; Mental disorders, treatment of; Psychoanalysis; Psychosis; and the biographies ofAbraham; Freud; Klein; Kraepelin.]

BIBLIOGRAPHY

Abraham, Karl (1912) 1953 Notes on the Psychoanalytical Investigation and Treatment of Manic–Depressive Insanity and Allied Conditions. Pages 137–156 in Karl Abraham, Selected Papers. Volume 1: Selected Papers on Psychoanalysis. New York: Basic Books. → First published in German.

Arieti, Silvano 1959a Manic–Depressive Psychosis. Volume 1, pages 419–454 in American Handbook of Psychiatry. Edited by Silvano Arieti. New York: Basic Books.

Arieti, Silvano 1959b Some Socio-cultural Aspects of Manic–Depressive Psychosis and Schizophrenia. Volume 4, pages 140–152 in Jacob Moreno and Jules Masserman (editors), Progress in Psychotherapy. New York: Grune.

Arieti, Silvano 1962 The Psychotherapeutic Approach to Depression. American Journal of Psychotherapy 16: 397–406.

Bellak, Leopold et al. 1952 Manic–Depressive Psychosis and Allied Conditions. New York: Grune.

Cerletti, Ugo 1950 Old and New Information About Electroshock. American Journal of Psychiatry 107: 87–94.

Eaton, Joseph W.; and Weil, Robert J. 1955 The Mental Health of the Hutterites. Pages 223–239 in Arnold M. Rose (editor), Mental Health and Mental Disorder: A Sociological Approach. Prepared for a committee of the Society for the Study of Social Problems. New York: Norton.

Freud, Sigmund (1917) 1959 Mourning and Melancholia. Volume 4, pages 152–170 in Sigmund Freud, Collected Papers, International Psycho-analytic Library, No. 10. New York: Basic Books; London: Hogarth. → Authorized translation from the German.

Gold, Henry R. 1951 Observations on Cultural Psychiatry During a World Tour of Mental Hospitals. American Journal of Psychiatry 108:462–468.

Klein, Melanie 1948 Contributions to Psycho-analysis: 1921–1945. International Psycho-analytic Library, No. 34. London: Hogarth.

Kraepelin, Emil (1883) 1921 Manic–Depressive Insanity and Paranoia. Edited by George M. Robertson. Edinburgh: Livingstone. → Translated from Volumes 3 and 4 of the eighth German edition of Psychiatrie.

Kraines, Samuel H. 1957 Mental Depressions and Their Treatment. New York: Macmillan.

RadÓ, SÁndor 1928 The Problem of Melancholia. International Journal of Psycho-analysis 9:420–438.

Rseiss, Max 1954 Investigations of Hormone Equilibria During Depression. Pages 69–82 in American Psycho-pathological Association, Forty-second Annual Meeting, New York, June 1952, Depression. Edited by Paul H. Hoch and Joseph Zubin. New York: Grune.

Riesman, David 1950 The Lonely Crowd: A Study of the Changing American Character. New Haven: Yale Univ. Press. → An abridged paperback edition was published in 1960.

Slater, Eliot 1936 The Inheritance of Manic–Depressive Insanity and Its Relation to Mental Defect. Journal of Mental Science 82:626–634.

Spitz, RenÉ A. 1946 Anaclitical Depression. Psychoanalytic Study of the Child 2:313–342.

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Depressive Disorders

Depressive disorders

Definition

Depression and depressive disorders (unipolar depression) are mental illnesses characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep , appetite, and mental processes are common symptoms of depression.

Description

Everyone experiences feelings of unhappiness and sadness occasionally. However, when these depressed feelings start to dominate everyday life and cause physical and mental deterioration, they become what are known as depressive disorders.

There are two main categories of depressive disorders: major depressive disorder and dysthymic disorder. Major depressive disorder is a moderate to severe episode of depression lasting two or more weeks. Individuals experiencing this major depressive episode may have trouble sleeping, lose interest in activities they once took pleasure in, experience a change in weight, have difficulty concentrating, feel worthless and hopeless, or have a preoccupation with death or suicide . In children, the major depression may often appear as irritability.

While major depressive episodes may be acute (intense but short-lived), dysthymic disorder is an ongoing, chronic depression that lasts two or more years (one or more years in children) and has an average duration of 16 years. The mild to moderate depression of dysthymic disorder may rise and fall in intensity, and those afflicted with the disorder may experience some periods of normal, non-depressed mood of up to two months in length. Its onset is gradual, and dysthymic patients may not be able to pinpoint exactly when they started feeling depressed. Individuals with dysthymic disorder may experience a change in sleeping and eating patterns, low self-esteem , fatigue, trouble concentrating, and feelings of hopelessness. Parents of children suffering from dysthymic disorder may notice their child experience a fall in grades and a lack of interest in extracurricular activities that were once enjoyable.

Depression also can occur in bipolar disorder , an affective mental illness that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Demographics

The Substance Abuse and Mental Health Services Administration (SAMSHA) estimates that one out of every 33 children may suffer from depression. Among adults 18 and older, depressive disorders affect an estimated 18.8 million Americans each year. Women are twice as likely to suffer from a depressive disorder than men; approximately 12.4 million American women and 6.4 million men deal with depression. The average age a first depressive episode occurs is in the mid-20s, although the disorder strikes all age groups indiscriminately, from children to the elderly.

According to the U.S. Surgeon General, major depression occurs in about 5 percent of children between age nine and 17, and at any one point in time, 10 to 15 percent of U.S. children and adolescents experience some symptoms of depression.

Causes and symptoms

The causes behind depression are complex and as of 2004 not fully understood. While an imbalance of certain neurotransmittersthe chemicals in the brain that transmit messages between nerve cellsis believed to be key to depression, external factors such as upbringing may be as important. For example, it is speculated that, if an individual is abused and neglected throughout childhood and adolescence , a pattern of low self-esteem and negative thinking may emerge. From that, a lifelong pattern of depression may follow.

Heredity seems to play a role in who develops depressive disorders. Individuals with major depression in their immediate family are up to three times more likely to have the disorder themselves. It would seem that biological and genetic factors may make certain individuals pre-disposed to depressive disorders, but environmental circumstances often may trigger the disorder as well.

External stressors and significant life changes such as chronic medical problems, death of a loved one, or divorce or estrangement of parents also can result in a form of depression known as adjustment disorder. Although periods of adjustment disorder usually resolve themselves, occasionally they may evolve into a major depressive disorder.

Common red flags that children may be experiencing a depressive disorder include a sudden decline in grades and/or disinterest in schoolwork, avoidance of friends, loss of interest in extracurricular activities, and withdrawal from family.

Major depressive episode

Individuals experiencing a major depressive episode have a depressed mood and/or a diminished interest or pleasure in activities. Children experiencing a major depressive episode may appear or feel irritable rather than depressed. In addition, five or more of the following symptoms will occur on an almost daily basis for a period of at least two weeks:

  • significant change in weight
  • insomnia or hypersomnia (excessive sleep)
  • psychomotor agitation or retardation
  • fatigue or loss of energy
  • feelings of worthlessness or inappropriate guilt
  • diminished ability to think or to concentrate, or indecisiveness
  • recurrent thoughts of death or suicide and/or suicide attempts

Dysthymic disorder

Dysthymia commonly occurs in tandem with other psychiatric and physical conditions. Up to 70 percent of dysthymic patients have both dysthymic disorder and major depressive disorder, known as double depression. Substance abuse, panic disorders, personality disorders , social phobias , and other psychiatric conditions also are found in many dysthymic patients. Dysthymia is prevalent in patients with certain medical conditions, including multiple sclerosis, AIDS , hypothyroidism , chronic fatigue syndrome, diabetes, and post-cardiac transplantation. The connection between dysthymic disorder and these medical conditions is unclear, but it may be related to the way the medical condition and/or its pharmacological treatment affects neurotransmitters. Dysthymic disorder can lengthen or complicate the recovery of patients also suffering from medical conditions.

Along with an underlying feeling of depression, people with dysthymic disorder experience two or more of the following symptoms on an almost daily basis for a period for two or more years (most suffer for five years) or one year or more for children:

  • under-eating or overeating
  • insomnia or hypersomnia
  • low energy or fatigue
  • low self-esteem
  • poor concentration or trouble making decisions
  • feelings of hopelessness

When to call the doctor

Just like adults, children have days when they are feeling down. But if those blue or bad moods begin to interfere with schoolwork and daily living and start to increase in frequency, parents or caregivers need to seek help from their child's doctor. If a child or teen reveals at any time that they have had recent thoughts of self-injury or suicide, professional assistance from a mental healthcare provider or care facility should be sought immediately.

Diagnosis

In addition to an interview, a clinical inventory or scale such as the Child Depression Inventory (CDI) or the Child Depression Rating Scale (CDRS) may be used to assess a child's mental status and determine the presence of depressive symptoms. Tests may be administered in an outpatient or hospital setting by a pediatrician, general practitioner, social worker, psychiatrist, or psychologist.

Treatment

Major depressive and dysthymic disorders are typically treated with antidepressants or psychosocial therapy. Psychosocial therapy focuses on the personal and interpersonal issues behind depression, while antidepressant medication is prescribed to provide more immediate relief for the symptoms of the disorder. When used together correctly, therapy and antidepressants are a powerful treatment plan for the depressed child or adolescent.

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety , diarrhea , drowsiness, headache , sweating, nausea , and insomnia all are possible side effects of SSRIs. As of 2004, fluoxetine was the only SSRI (and the only antidepressant drug) approved by the U.S. Food and Drug Administration for use in children and adolescents with major depressive disorder. However, physicians may prescribe other SSRIs in younger patients in an off-label use of these drugs.

In 2004, fluoxetine and nine other antidepressant drugs came under scrutiny when the FDA issued a public health advisory and announced it was requesting the addition of a warning statement in drug labeling that outlined the possibility of worsening depression and increased suicide risk. These developments were the result of several clinical studies that found that some children taking these antidepressants had an increased risk of suicidal thoughts and actions. The FDA announced at the time that the agency would embark on a more extensive analysis of the data from these clinical trials and decide if further regulatory action was necessary.

Older classes of antidepressant drugs(tricyclic antidepressants (TCAs), heterocyclics, and monoamine oxidase inhibitors (MAOIs)do not have any substantial demonstrated effectiveness in pediatric populations and have potentially serious side effects that make them undesirable for child and adolescent use.

For severe depression that does not respond well to antidepressant, mood stabilizer drugs (e.g., lithium, carbamazepine, valproic acid) may be recommended.

Diagnosis Symptoms Treatment
source: Academy of American Family Physicians. 2000. http://www.aafp.org.
Sadness Transient, normal depressive response or mood change due to stress. Emotional support
Bereavement Sadness related to a major loss that persists for less than two months after the loss. Thoughts of death and morbid preoccupation with worthlessness are also present. Emotional support; counseling
Sadness problem Sadness or irritability that begins to resemble major depressive disorder, but lower in severity and more transient. Support; counseling; medication possible
Adjustment disorder with depressed mood Symptoms include depressed mood, tearfulness, and hopelessness, and occur within three months of an identifiable stressor. Symptoms resolve in six months. Psychotherapy; medication
Major depressive disorder A depressed or irritable mood or diminished pleasure as well as three to seven of the following criteria almost daily for two weeks. The criteria include: recurrent thoughts of death and suicidal ideation; weight loss or gain; fatigue or energy loss; feelings of worthlessness; diminished ability to concentrate; insomnia or hypersomnia; feeling hyper and jittery, or abnormally slow. Psychotherapy; medication
Dysthymic disorder Depressed mood for most of the day, for more days than not, for one year, including the presence of two of the following symptoms: poor appetite or overeating; insomnia/hypersomnia; low energy/fatigue; poor concentration; feelings of hopelessness. Symptoms are less severe than those of a major depressive episode but are more persistent. Psychotherapy; medication
Bipolar I disorder, most recent episode depressed Current major depressive episode with a history of one manic or mixed episode. (Manic episode is longer than four days and causes significant impairment in normal functioning.) Moods are not accounted for by another psychiatric disorder. Psychotherapy; medication
Bipolar II disorder, recurrent major depressive episodes with hypomanic episodes Presence or history of one major depressive episode and one hypomanic episode (similar to manic episode but shorter and less severe). Symptoms are not accounted for by another psychiatric disorder and cause clinically significant impairment in functioning. Psychotherapy; medication

Psychotherapy

Psychotherapy, or talk therapy, involves analyzing a child's life to bring to light possible contributing causes of the present depression. During treatment, the therapist helps the patient to become aware of his or her thinking patterns and how they came to be, and works with them to develop healthy problem solving and copying skills. In very young patients, a therapist may use toys , games, and dolls as a vehicle for helping a child express her emotions. This type of therapy, sometimes referred to as play therapy, is useful in children who may not have the developmental capacity or language skills to express the thoughts and feelings behind their depression.

Cognitive-behavioral therapy assumes that the patient's faulty thinking is causing the current depression and focuses on changing the depressed patient's thought patterns and perceptions. The therapist helps the patient identify negative or distorted thought patterns and the emotions and behavior that accompany them and then retrains the depressed individual to recognize the thinking and react differently to it.

Electroconvulsant therapy

Electroconvulsive therapy (ECT) is only considered after all therapy and pharmaceutical treatment options have been unsuccessful, and even then it is a treatment of last resort, typically employed when a patient has become catatonic, suicidal, or psychotic as well as depressed.

The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under anesthesia, and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Memory loss, typically transient, also has been reported in ECT patients.

Alternative treatment

St. John's wort (Hypericum perforatum ) isused throughout Europe to treat mild depressive symptoms. Unlike traditional prescription antidepressants, this herbal antidepressant has few reported side effects. Despite uncertainty concerning its effectiveness, a 2003 report said acceptance of the treatment continues to increase. A poll showed that about 41 percent of 15,000 science professionals in 62 countries said they would use St. John's wort for mild to moderate depression. The usual adult dose is 300 mg three times daily and may be lowered for children and adolescents.

In several small studies, S-adenosyl-methionine (SAM, SAMe) was shown to be more effective than placebo and equally effective as tricyclic antidepressants in treating depression. In 2003, a U.S. Department of Health and Human Services team reviewed 100 clinical trials on SAMe and concluded that it worked as well as many prescription medications without side effects of stomach upset.

Parents and caregivers of children who suffer from depression should consult their child's physician before administering any herb or dietary supplement. Some supplements can interfere with the action of other prescription and over-the-counter medications. In addition, some supplements may not be appropriate for use in children with certain medical conditions.

A report from Great Britain published in 2003 emphasized that more physicians should encourage alternative treatments such as behavioral and self-help programs, supervised exercise programs, and watchful waiting before subscribing antidepressant medications for mild depression.

Nutritional concerns

Poor nutrition , especially eating habits that lead to overweight or obesity in children, can also contribute to depression. A 2003 study in the journal Pediatrics found that children who are substantially overweight for long periods of time are more likely to suffer from depression. Whether the depression causes the weight problem or the weight issue triggers the depression was not completely clear.

Prognosis

Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 80 to 90 percent of depressed patients. After each major depressive episode, the risk of recurrence climbs significantly: 50 percent after one episode, 70 percent after two episodes, and 90 percent after three episodes. For this reason, patients need to be aware of the symptoms of recurring depression and may require long-term maintenance treatment of antidepressants and/or therapy.

Prevention

Good nutrition, proper sleep, exercise, and family support are all important to a healthy mental state, particularly in children. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Early intervention for children with depression can be effective in avoiding the development of more severe psychological problems later in life.

Parental concerns

Children who are diagnosed with depression should be reassured that the condition is quite common and that it is due to factors beyond their control (i.e., genetics, neurochemical imbalance) rather than any fault of the child. For those children and teens who feel stigmatized or self-conscious about their depression, arranging psychotherapy sessions outside school hours may lessen their burden. Any child prescribed antidepressants should be carefully monitored for any sign of side effects, and these should be reported to their physician when they do occur. A dosage adjustment or medication change may be warranted if side effects are disruptive or potentially dangerous.

KEY TERMS

Hypersomnia An abnormal increase of 25% or more in time spent sleeping. Individuals with hypersomnia usually have excessive daytime sleepiness.

Neurotransmitter A chemical messenger that transmits an impulse from one nerve cell to the next.

Psychomotor agitation Disturbed physical and mental processes (e.g., fidgeting, wringing of hands, racing thoughts); a symptom of major depressive disorder.

Psychomotor retardation Slowed mental and physical processes characteristic of a bipolar depressive episode.

See also Bipolar disorder.

Resources

BOOKS

Barnard, Martha Underwood. Helping Your Depressed Child. Oakland, CA: New Harbinger Publications, 2003.

Diagnostic and Statistical Manual of Mental Disorders,4th ed., text revision (DSM-IV-TR). Washington, DC: American Psychiatric Press, 2000.

Shaffer, David, and Bruce Waslick, eds. The Many Faces of Depression in Children and Adolescents. Arlington, VA: American Psychiatric Publishing, 2002.

PERIODICALS

"A Natural Mood-Booster that Really Works: A Group of Noted Researchers Found that the Supplement SAMe Works as Well as Antidepressant Drugs." Natural Health (July 2003): 22.

"FDA Approves Once-daily Supplement." Biotech Week (September 24, 2003): 6.

"Try Alternatives Before Using Antidepressants." GP (September 29, 2003): 12.

Vitiello, B., and S. Swedo. "Antidepressant Medications in Children." New England Journal of Medicine 350, no. 15 (April 8, 2003): 148991.

ORGANIZATIONS

American Psychiatric Association. 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209. Web site: <www.psych.org>.

American Psychological Association (APA). 750 First St. NE, Washington, DC 200024242. Web site: <www.apa.org>.

Depression and Bipolar Support Alliance (DBSA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. Web site: <www.dbsalliance.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 222013042. Web site: <www.nami.org>.

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Blvd., Room 8184, MSC 9663, Bethesda, MD 208929663. Web site: <www.nimh.nih.gov>.

WEB SITES

Larsen, Willow. "The Obesity-Depression Link." Psychology Today (May 30, 2003). Available online at <www.psychologytoday.com/htdocs/prod/ptoarticle/pto-20030527-000010.asp> (accessed December 26, 2004).

U.S. Food and Drug Administration. "Antidepressant [links]." Available online at <www.fda.gov> (accessed December 26, 2004).

Paula Ford-Martin Teresa Odle

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Ford-Martin, Paula; Odle, Teresa. "Depressive Disorders." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Encyclopedia.com. 27 Sep. 2016 <http://www.encyclopedia.com>.

Ford-Martin, Paula; Odle, Teresa. "Depressive Disorders." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Encyclopedia.com. (September 27, 2016). http://www.encyclopedia.com/doc/1G2-3447200184.html

Ford-Martin, Paula; Odle, Teresa. "Depressive Disorders." Gale Encyclopedia of Children's Health: Infancy through Adolescence. 2006. Retrieved September 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3447200184.html

Depressive Disorders

Depressive Disorders

Definition

Depression or depressive disorders (unipolar depression) are mental illnesses characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep, appetite, and mental processes are a common accompaniment.

Description

Everyone experiences feelings of unhappiness and sadness occasionally. But when these depressed feelings start to dominate everyday life and cause physical and mental deterioration, they become what are known as depressive disorders. Each year in the United States, depressive disorders affect an estimated 17 million people at an approximate annual direct and indirect cost of $53 billion. One in four women is likely to experience an episode of severe depression in her lifetime, with a 10-20% lifetime prevalence, compared to 5-10% for men. The average age a first depressive episode occurs is in the mid-20s, although the disorder strikes all age groups indiscriminately, from children to the elderly.

There are two main categories of depressive disorders: major depressive disorder and dysthymic disorder. Major depressive disorder is a moderate to severe episode of depression lasting two or more weeks. Individuals experiencing this major depressive episode may have trouble sleeping, lose interest in activities they once took pleasure in, experience a change in weight, have difficulty concentrating, feel worthless and hopeless, or have a preoccupation with death or suicide. In children, the major depression may appear as irritability.

While major depressive episodes may be acute (intense but short-lived), dysthymic disorder is an ongoing, chronic depression that lasts two or more years (one or more years in children) and has an average duration of 16 years. The mild to moderate depression of dysthymic disorder may rise and fall in intensity, and those afflicted with the disorder may experience some periods of normal, non-depressed mood of up to two months in length. Its onset is gradual, and dysthymic patients may not be able to pinpoint exactly when they started feeling depressed. Individuals with dysthymic disorder may experience a change in sleeping and eating patterns, low self-esteem, fatigue, trouble concentrating, and feelings of hopelessness.

Depression also can occur in bipolar disorder, an affective mental illness that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Causes and symptoms

The causes behind depression are complex and not yet fully understood. While an imbalance of certain neurotransmittersthe chemicals in the brain that transmit messages between nerve cellsis believed to be key to depression, external factors such as upbringing (more so in dysthymia than major depression) may be as important. For example, it is speculated that, if an individual is abused and neglected throughout childhood and adolescence, a pattern of low self-esteem and negative thinking may emerge. From that, a lifelong pattern of depression may follow. A 2003 study reported that two-thirds of patients with major depression say they also suffer from chronic pain. A 2004 study linked severe obesity with major depression. Another study showed a strong relationship between smoking and depression among teens.

Heredity seems to play a role in who develops depressive disorders. Individuals with major depression in their immediate family are up to three times more likely to have the disorder themselves. It would seem that biological and genetic factors may make certain individuals pre-disposed or prone to depressive disorders, but environmental circumstances often may trigger the disorder.

External stressors and significant life changes, such as chronic medical problems, death of a loved one, divorce or estrangement, miscarriage, or loss of a job, also can result in a form of depression known as adjustment disorder. Although periods of adjustment disorder usually resolve themselves, occasionally they may evolve into a major depressive disorder.

Major depressive episode

Individuals experiencing a major depressive episode have a depressed mood and/or a diminished interest or pleasure in activities. Children experiencing a major depressive episode may appear or feel irritable rather than depressed. In addition, five or more of the following symptoms will occur on an almost daily basis for a period of at least two weeks:

  • Significant change in weight.
  • Insomnia or hypersomnia (excessive sleep).
  • Psychomotor agitation or retardation.
  • Fatigue or loss of energy.
  • Feelings of worthlessness or inappropriate guilt.
  • Diminished ability to think or to concentrate, or indecisiveness.
  • Recurrent thoughts of death or suicide and/or suicide attempts.

Dysthymic disorder

Dysthymia commonly occurs in tandem with other psychiatric and physical conditions. Up to 70% of dysthymic patients have both dysthymic disorder and major depressive disorder, known as double depression. Substance abuse, panic disorders, personality disorders, social phobias, and other psychiatric conditions also are found in many dysthymic patients. Dysthymia is prevalent in patients with certain medical conditions, including multiple sclerosis, AIDS, hypothyroidism, chronic fatigue syndrome, Parkinson's disease, diabetes, and post-cardiac transplantation. The connection between dysthymic disorder and these medical conditions is unclear, but it may be related to the way the medical condition and/or its pharmacological treatment affects neurotransmitters. Dysthymic disorder can lengthen or complicate the recovery of patients also suffering from medical conditions.

Along with an underlying feeling of depression, people with dysthymic disorder experience two or more of the following symptoms on an almost daily basis for a period for two or more years (most suffer for five years), or one year or more for children:

  • under or overeating
  • insomnia or hypersomnia
  • low energy or fatigue
  • low self-esteem
  • poor concentration or trouble making decisions
  • feelings of hopelessness

Signs of Depression

Lack of interest or pleasure in daily activities

Significant weight loss (without dieting) or weight gain

Difficulty sleeping or excessive sleeping

Loss of energy

Feelings of worthlessness or guilt

Difficulty in making decisions

Restlessness

Recurrent thoughts of death

Diagnosis

In addition to an interview, several clinical inventories or scales may be used to assess a patient's mental status and determine the presence of depressive symptoms. Among these tests are: the Hamilton Depression Scale (HAM-D), Child Depression Inventory (CDI), Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), and the Zung Self-Rating Scale for Depression. These tests may be administered in an outpatient or hospital setting by a general practitioner, social worker, psychiatrist, or psychologist.

Treatment

Major depressive and dysthymic disorders are typically treated with antidepressants or psychosocial therapy. Psychosocial therapy focuses on the personal and interpersonal issues behind depression, while antidepressant medication is prescribed to provide more immediate relief for the symptoms of the disorder. When used together correctly, therapy and antidepressants are a powerful treatment plan for the depressed patient.

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, poor sexual functioning, and insomnia all are possible side effects of SSRIs. In early 2004, a joint panel of the U.S. Food and Drug Administration (FDA) issued stronger warnings to physicians and parents about increased risk of suicide among children and adolescents taking SSRIs.

Tricyclic antidepressants (TCAs) are less expensive than SSRIs, but have more severe side-effects, which may include persistent dry mouth, sedation, dizziness, and cardiac arrhythmias. Because of these side effects, caution is taken when prescribing TCAs to elderly patients. TCAs include amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). A 10-day supply of TCAs can be lethal if ingested all at once, so these drugs may not be a preferred treatment option for patients at risk for suicide.

Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid potentially serious hypertensive side effects.

Heterocyclics include bupropion (Wellbutrin) and trazodone (Desyrel). Bupropion should not be prescribed to patients with a seizure disorder. Side effects of the drug may include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, low blood pressure, and insomnia. Because trazodone has a sedative effect, it is useful in treating depressed patients with insomnia. Other possible side effects of trazodone include dry mouth, gastrointestinal distress, dizziness, and headache. In 2003, Wellbutrin's manufacturer released a oncedaily version of the drug that offered low risk of sexual side effects or weight gain.

Psychosocial therapy

Psychotherapy explores an individual's life to bring to light possible contributing causes of the present depression. During treatment, the therapist helps the patient to become self-aware of his or her thinking patterns and how they came to be. There are several different subtypes of psychotherapy, but all have the common goal of helping the patient develop healthy problem solving and coping skills.

Cognitive-behavioral therapy assumes that the patient's faulty thinking is causing the current depression and focuses on changing the depressed patient's thought patterns and perceptions. The therapist helps the patient identify negative or distorted thought patterns and the emotions and behavior that accompany them, and then retrains the depressed individual to recognize the thinking and react differently to it.

Electroconvulsant therapy

ECT, or electroconvulsive therapy, usually is employed after all therapy and pharmaceutical treatment options have been explored. However, it is sometimes used early in treatment when severe depression is present and the patient refuses oral medication, or when the patient is becoming dehydrated, extremely suicidal, or psychotic.

The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under general anesthesia and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Memory loss, typically transient, also has been reported in ECT patients.

Alternative treatment

St. John's wort (Hypericum perforatum ) is used throughout Europe to treat depressive symptoms. Unlike traditional prescription antidepressants, this herbal antidepressant has few reported side effects. Despite uncertainty concerning its effectiveness, a 2003 report said acceptance of the treatment continues to increase. A poll showed that about 41% of 15,000 science professionals in 62 countries said they would use St. John's wort for mild to moderate depression. Although St. John's wort appears to be a safe alternative to conventional antidepressants, care should be taken, as the herb can interfere with the actions of some pharmaceuticals. The usual dose is 300 mg three times daily.

Homeopathic treatment also can be therapeutic in treating depression. Good nutrition, proper sleep, exercise, and full engagement in life are very important to a healthy mental state.

In several small studies, S-adenosyl-methionine (SAM, SAMe) was shown to be more effective than placebo and equally effective as tricyclic antidepressants in treating depression. The usual dosage is 200 mg to 400 mg twice daily. In 2003, a U.S. Department of Health and Human Services team reviewed 100 clinical trials on SAMe and concluded that it worked as well as many prescription medications without the side effects of stomach upset and decreased sexual desire.

In 2003, a report from Great Britain emphasized that more physicians should encourage alternative treatments such as behavioral and self-help programs, supervised exercise programs, and watchful waiting before subscribing antidepressant medications for mild depression.

Prognosis

Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 80-90% of depressed patients. After each major depressive episode, the risk of recurrence climbs significantly50% after one episode, 70% after two episodes, and 90% after three episodes. For this reason, patients need to be aware of the symptoms of recurring depression and may require long-term maintenance treatment of antidepressants and/or therapy.

Research has found that depression may lead to other problems as well. Increased risk of heart disease has been linked to depression, particularly in post-menopausal women. And while chronic pain may cause depression, a 2004 study in Canada revealed that depression also may lead to back pain.

Prevention

Patient education in the form of therapy or self-help groups is crucial for training patients with depressive disorders to recognize symptoms of depression and to take an active part in their treatment program. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Early intervention for children with depression is effective in arresting development of more severe problems.

KEY TERMS

Hypersomnia The need to sleep excessively; a symptom of dysthymic and major depressive disorder.

Neurotransmitter A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to depressive disorders.

Psychomotor agitation Disturbed physical and mental processes (e.g., fidgeting, wringing of hands, racing thoughts); a symptom of major depressive disorder.

Psychomotor retardation Slowed physical and mental processes (e.g., slowed thinking, walking, and talking); a symptom of major depressive disorder.

Resources

PERIODICALS

"Depression Can Lead to Back Pain." Biotech Week, March 24, 2004: 576.

"Depression May Be a Risk Factor for Heart Disease, Death in Older Women." Women's Health Weekly, March 4, 2004: 90.

"FDA Approves Once-daily Supplement." Biotech Week, September 24, 2003: 6.

"FDA Panel Urges Stronger Warnings of Child Suicide." SCRIP World Pharmaceutical News, February 6, 2004: 24.

Jancin, Bruce. "Chronic Pain Affects 67% of Patients With Depression: 'Stunning' Finding in Primary Care Study." Internal Medicine News, September 15, 2003: 4.

"National Study Indicates Obesity Is Linked to Major Depression." Drug Week, February 13, 2004: 338.

"A Natural Mood-booster that Really Works: a Group of Noted Researchers Found that the Supplement SAMe Works as Well as Antidepressant Drugs." Natural Health, July 2003: 22.

"Researchers See Link Between Depression, Smoking." Mental Health Weekly, March 1, 2004: 8.

"St. John's Wort Healing Reputation Upheld." Nutraceuticals International, September 2003.

"Try Alternatives Before Using Antidepressants." GP, September 29, 2003: 12.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. http://www.psych.org.

American Psychological Association (APA). 750 First St. NE, Washington, DC 20002-4242. (202) 336-5700. http://www.apa.org.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. http://www.nami.org.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. http://www.ndmda.org.

National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. http://www.nimh.nih.gov.

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Ford-Martin, Paula; Odle, Teresa. "Depressive Disorders." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. 27 Sep. 2016 <http://www.encyclopedia.com>.

Ford-Martin, Paula; Odle, Teresa. "Depressive Disorders." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. (September 27, 2016). http://www.encyclopedia.com/doc/1G2-3451600498.html

Ford-Martin, Paula; Odle, Teresa. "Depressive Disorders." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved September 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451600498.html

Depressive Disorders

DEPRESSIVE DISORDERS

DEFINITION


Depressive disorders are mental illnesses characterized by deep, long-lasting feelings of sadness or despair. The patient may also lose interest in things that were once pleasurable. Changes in sleep patterns, appetite, and mental processes may also accompany depressive disorders. Depressive disorders are also known simply as depression or as unipolar (one-sided) depression.

DESCRIPTION


Everyone experiences feelings of unhappiness and sadness occasionally. In some cases, however, these feelings can begin to take over a person's everyday life. They cause a person's physical and mental health to deteriorate.

Experts estimate that depressive disorders affect seventeen million Americans. One in four women is likely to experience at least one episode of depressive disorder in her lifetime. The rate is about one in eight among men. Depressive disorders can strike all age groups, from children to the elderly. The average age a first depressive episode occurs is in the middle twenties.

Depressive Disorders: Words to Know

Dysthymic disorder:
An ongoing, chronic depression that lasts two or more years.
Hypersomnia:
The need to sleep excessively; a symptom of dysthymic and major depressive disorder.
Neurotransmitters:
Chemicals that occur in the brain and are responsible for carrying messages in the brain.
Psychosocial therapy:
Any means by which a trained professional holds interviews with a patient and tries to help that patient better understand himself or herself and the reasons for his or her thoughts and actions.

There are two types of depressive disorders: major depressive disorder and dysthymic (pronounced dis-THIH-mik) disorder. Major depressive disorder is defined as a depressive disorder with moderate to severe symptoms that lasts two or more weeks. The symptoms of major depressive disorder include trouble sleeping, loss of interest in once enjoyable activities, change in weight, difficulty in concentrating, feelings of hopelessness, and thoughts about death and suicide. In children, the main symptom of major depressive disorder is irritability (being easily upset).

Dysthymic disorder is a chronic (ongoing) form of depression that lasts at least two years (one year in children). The average period of time the disorder lasts is sixteen years. The symptoms of dysthymic disorder tend to be mild to moderate. They may be more intense at some times than at others. A person with dysthymic disorder may go for up to two months without feeling depressed. The disorder often comes on gradually. A patient may not even remember exactly when he or she started feeling depressed. Symptoms of dysthymic disorder include problems with sleeping and eating, low self-esteem (poor feelings about oneself), trouble concentrating, and feelings of hopelessness.

Depression can also occur in bipolar disorder (see bipolar disorder entry). Bipolar is a form of mental illness in which people feel wild swings of emotions. At one moment, they may feel happy and optimistic. At the next moment, they may feel sad and depressed.

CAUSES


The causes of depressive disorders are not well understood. Most experts believe that an imbalance of neurotransmitters is a major factor. Neurotransmitters are chemicals in the brain. They are responsible for carrying messages from one part of the brain to another. The presence of too many or too few neurotransmitters can cause the brain to perform abnormally.

Environmental factors are also thought to be involved in depressive disorders. It is believed that children who are abused or neglected may later develop a depressive disorder.

Heredity also seems to play a role in depressive disorders. People whose families have a history of major depression are up to three times more likely to have the disorder themselves. Many scientists now think that genetic and environmental factors work together to cause depressive disorder. Heredity may predispose (make a person more likely to have) a person toward depressive disorder. But the condition develops only if the environment in which he or she grows up allows the condition to appear.

SYMPTOMS


Symptoms of depressive disorders vary depending whether the depression is caused by major depressive disorder or dysthymic disorder.

Major Depressive Episode

A person going through a major depressive episode feels depressed and/or loses interest in enjoyable activities. Children are more likely to feel irritable than depressed. In addition, five or more of the following symptoms appear on an almost daily basis for a period of at least two weeks:

  • Significant change in weight
  • Insomnia (inability to sleep) or hypersomnia (excessive sleep)
  • Extreme tiredness or loss of energy
  • Feelings of worthlessness and guilt that have no basis
  • Diminished ability to think or to concentrate, or the loss of ability to make decisions
  • Continuing thoughts of death or suicide and/or actual attempts at suicide

Dysthymic Disorder

The symptoms of dysthymic disorder occur along with other mental and physical symptoms. Up to 70 percent of dysthymic patients also have major depressive disorder. This condition is known as double depression. Some mental problems seen in people with dysthymic disorder include substance abuse (drug abuse), panic disorders (see panic disorders entry), and phobias (irrational fears). Physical problems that accompany dysthymia include multiple sclerosis (see multiple sclerosis entry), AIDS (see AIDS entry), chronic fatigue syndrome (see chronic fatigue syndrome entry), diabetes (see diabetes mellitus entry), and Parkinson's disease (see Parkinson's disease entry).

Scientists do not understand why dysthymic disorders are connected with these physical problems. They think the medical condition or the drugs used for treatment can affect the way a person's neurotransmitters operate in the brain.

SIGNS OF MENTAL DEPRESSION

Depressed mood

Lack of interest or pleasure in daily activities

Significant weight loss (without dieting) or weight gain

Difficulty sleeping or excessive sleeping

Loss of energy

Feelings of worthlessness or guilt

Difficulty in making decisions

Restlessness

Recurrent thoughts of death

(Reproduced by permission of Stanley Publishing)

In addition to feelings of depression, patients with dysthymic disorder also experience two or more of the following symptoms on an

almost daily basis for a period of two or more years (one or more years in children):

  • Under-eating or overeating
  • Insomnia or hypersomnia
  • Low energy or fatigue (extreme tiredness)
  • Low self-esteem
  • Poor concentration or trouble making decisions
  • Feelings of hopelessness

DIAGNOSIS


The first step in diagnosing a depressive disorder is an interview with the patient. The interview is followed by one or more tests designed to find out how depressed the patient is. Examples of these tests include the Hamilton Depression Scale, Child Depression Inventory, Geriatric Depression Scale, and Beck Depression Inventory. These tests are given by a doctor, social worker, psychologist, or psychiatrist in his or her office or in a hospital.

TREATMENT


Depressive disorders are treated by one or more of three methods: drugs, psychosocial therapy, or electroconvulsive (pronounced ih-LEK-tro cun-VUL-siv) therapy (ECT). Many drugs seem to work because of changes they produce in the way neurotransmitters work in the brain. Psychosocial therapy consists of interviews between the patient and a trained specialist to find out the causes of a person's depression. ECT makes use of severe electrical shocks to treat a person's depression.

Antidepressants

One group of drugs used to treat depression is called selective serotonin re-uptake inhibitors (SSRIs). These drugs increase the amount of serotonin (pronounced sehr-uh-TOE-nun) in the brain. Serotonin is a major neuro-transmitter. Some side effects of SSRIs include anxiety, diarrhea, drowsiness, headache, sweating, nausea, poor sexual functioning, and insomnia (see insomnia entry).

Another group of drug is the tricyclic antidepressants (TCAs). They are less expensive than SSRIs, but they have more side effects. These side effects include dry mouth, dizziness, and heart problems. Because of these effects, TCAs are often not recommended for elderly patients. They are also not recommended for suicidal patients since, if they are taken in large quantities, they cause death.

Monoamine oxidase inhibitors (MAO inhibitors) also act on chemicals present in the brain to relieve the symptoms of depression. One risk in using MAO inhibitors is that they react with certain foods, such as aged cheese and meats, to produce dangerous side effects.

Psychosocial Therapy

The purpose of psychosocial therapy is to discover possible causes for a person's depression. A therapist helps the patient to understand himself or herself better. This self-understanding may help the patient overcome the problems that led to depression.

One form of psychosocial therapy is called cognitive-behavioral therapy. The therapist helps the patient to recognize thought patterns (such as thinking about suicide) that lead to depression. The patient is then trained to change those negative thought patterns to positive patterns. If successful, this therapy can help relieve the symptoms of depression.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is usually a treatment of last resort. It is tried when neither drugs nor psychosocial therapy have been very helpful with a patient. In rare cases, it is used if a patient refuses to take oral medication (drugs taken by mouth) or the patient is suicidal or out of touch with reality.

ECT consists of a series of electrical shocks administered to a patient's brain. The patient is first put to sleep with a general anesthetic and is given muscle relaxants. The muscle relaxants prevent violent responses to the electric shock that can result in broken bones. ECT is accompanied by a number of side effects, such as headache, muscle soreness, nausea, confusion, and memory loss.

No one knows how ECT works or what effects it has on the brain. In fact, some experts believe that the treatment is too dangerous to use with patients. Under the best circumstances, they say, it should be tried only in the most serious cases that do not respond to any other form of treatment.

Alternative Treatment

The herb known as St. John's wort is used throughout Europe to treat depression. Unlike prescription drugs, it has few side effects. Thus far, there is no scientific evidence about the effectiveness of this herb for the treatment of depression.

Some simple methods for increasing one's mental health include a healthy diet, proper sleep, exercise, and participation in many interesting daily activities.

PROGNOSIS


Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 80 to 90 percent of all patients. The occurrence of a single episode of depression increases the chances of another such episode. After one episode, a person is 50 percent more likely to have a second episode. After a second episode, the risk rises to 70 percent for a third episode. And after a third episode, the risk reaches 90 percent for yet another episode. For this reason, patients with recurrent (repeated) episodes may require long-term treatment with drugs and/or psychosocial therapy.

PREVENTION


The basic causes of depression, such as problems with brain chemicals and heredity, may not be preventable. But anyone who has experienced the feelings of depression can do a great deal to prevent the disorder from developing. People can be taught to recognize the symptoms of depression and to know how to prevent the condition from becoming worse. In many cases, simply staying with a medication program can relieve many of the symptoms of depression. With children, the sooner treatments begin, the more likely they are to be effective.

See also: Bipolar disorder, seasonal affective disorder.

FOR MORE INFORMATION


Books

Copeland, Mary Ellen. The Depression Workbook: A Guide for Living With Depression and Manic Depression. Oakland, CA: New Harbinger Publications, 1992.

O'Connor, Richard. Undoing Depression: What Therapy Doesn't Teach You and Medication Can't Give You. Boston: Little Brown, 1997.

Thompson, Tracy. The Beast: A Reckoning with Depression. New York: G. P. Putnam, 1995.

Thorne, Julia. You Are Not Alone: Words of Experience and Hope for the Journey Through Depression. New York: Harperperennial Library, 1993.

Whybrow, Peter. A Mood Apart. New York: Harper Collins, 1997.

Periodicals

Miller, Sue, "A Natural Mood Booster." Newsweek (May 5, 1997): pp. 7475.

Organizations

American Psychiatric Association (APA). Office of Public Affairs. 1400 K Street, NW, Washington, DC 20005. (202) 6826119. http://www.psych.org.

American Psychological Association (APA). Office of Public Affairs. 750 First St., NE, Washington, DC 200024242. (202) 3365700. http://www.apa.org.

National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, suite 1015, Arlington, VA 222033754. (800) 9506264. http://www.nami.org.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 8263632. http://www.ndmda.org.

National Institute of Mental Health (NIMH). 5600 Fishers Lane, Rm. 7C-02. Bethesda, MD 20857. (301) 4434513. http://www.nimh.nih.gov/.

Web Sites

"Ask NOAH About: Mental Health." NOAH: New York Online Access to Health. [Online] http://www.noah.cuny.edu/mentalhealth/mental.html (accessed on October 7, 1999).

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