depression
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Depression

Depression


adultsian h. gotlib, karen l. kasch

children and adolescentsjudith semon dubas,anne c. petersen


ADULTS


Major depression is a syndrome that affects 15 to 20 percent of the population. It is among the most prevalent of all psychiatric disorders. Moreover, twice as many women than men comprise the 15 to 20 percent of the population who will experience a clinically significant episode of depression at some point in their lives. Major Depressive Disorder, the diagnostic label for a clinically significant episode of depression, is characterized by at least a two-week period of persistent sad mood or a loss of interest or pleasure in daily activities, and four or more additional symptoms, such as marked changes in weight or appetite, sleep disturbance, restlessness or slowing of thoughts and movements, fatigue, feelings of guilt or worthlessness, concentration difficulties, and thoughts of suicide. Although there are clearly difficulties in attempting to study depression in different cultures (Tsai and Chentsova-Dutton 2002), the prevalence of depression varies widely across the world. In general, Asian countries, such as Japan and Taiwan, have the lowest documented lifetime prevalence rates of depression (both approximately 1.5%); poorer countries like Chile have the highest rates (27%); the United States and other Western countries have intermediate lifetime prevalence rates of depression (Tsai and Chentsova-Dutton 2002). It is interesting to note that studies have shown that Mexicans born in Mexico have lower rates of depression, while those born in the United States have rates the same as non-Hispanic whites (Golding, Karno, and Rutter 1990; Golding and Burnam 1990). In general, the more acculturated Mexican-Americans are, the less likely they are to experience depression. However, those with more acculturative stress (e.g., coping with a move from being high status in Mexico to being lower status in the United States) tend to experience more depression than those with less acculturative stress (Hovey 2000).

The relatively high rates of depression have led the World Health Organization Global Burden of Disease Study to rank this disorder as the single most burdensome disease in the world in terms of total disability-adjusted life years (Murray and Lopez 1996). More importantly, depression not only has a high prevalence rate, but also has a high rate of recurrence. Over 75 percent of depressed patients have more than one depressive episode (Boland and Keller 2002), often developing a relapse of depression within two years of recovery from a depressive episode. This high recurrence rate in depression suggests that there are specific factors that increase people's risk for developing repeated episodes of this disorder. In attempting to understand this elevated risk for depression, investigators have examined genetic and biological factors, and psychological and environmental characteristics, that may lead individuals to experience depressive episodes.

Some forms of depression have a strong genetic influence. Depression has been shown to run in biological families; indeed, having a biological relative with a history of depression increases a person's risk for developing an episode of depression. Furthermore, twin research has consistently and reliably demonstrated that major depression is a heritable condition (e.g., Kendler and Aggen 2001). Research using broad definitions of depression suggests that men and women have different heritabilities for depression, with genetic factors proving more etiologically important for women than for men (Kendler and Aggen 2001). Gaining a better understanding of this difference in heritabilities may help to elucidate the reasons underlying the higher rates of depression in women than in men.

Although genetic factors are important, they do not fully explain the etiology of depression. For example, there are sets of identical (monozygotic) twins in which one is affected with depression and the other never becomes depressed. Because monozygotic twins have identical genetic makeups, these differences must be due to factors that the twins do not share. Some of these factors are biological (but not genetic). There is abundant evidence that biology can affect mood. For example, thyroid problems can often mimic depression and cause weight changes, sad mood, and other symptoms of depression. Similarly, investigators have demonstrated some drugs or medications (e.g., reserpine) can induce a depression-like syndrome, whereas other medications (e.g., antidepressants) are effective in alleviating depressed mood. These medications generally affect the neurotransmitters implicated in depression. Biological factors can also affect the risk for depression. For instance, obstetrical complications seem to increase the risk of developing depression later in life (Fan and Eaton 2000; Preti et al. 2000). In addition, because in virtually every culture women are at greater risk for depression than are men (cf. Nolen-Hoeksema 1990), it is likely that something about the biology of being female, such as hormonal functioning, may make depression more likely to occur.

There are also psychosocial influences in the development of depression. Some research suggests, for example, that a childhood history of abuse or neglect can put an adult at greater risk for depression (e.g., Bifulco, Brown, and Adler 1991). Moreover, there is evidence that a history of abuse may be related to suicidal thoughts and behavior both in patients and nonpatients, above and beyond the effects of having a diagnosis of depression (Read et al. 2001; Molnar, Berkman, and Buka 2001). Furthermore, social support (e.g., from friends or family) can mitigate depression, whereas a lack of support may increase the severity or length of a depressive episode (George et al. 1989; Goering, Lancee, and Freeman 1992). Finally, there appears to be a robust link between stressful life events (e.g., divorce, bankruptcy) and the onset of major depression, suggesting that such events may play a role in the etiology of some major depressive episodes (Stueve, Dohrenwend, and Skodol 1998). Recent studies have examined the impact of befriending as an intervention for women with chronic depression, and have found that the addition of such social support had a positive impact on the depression, further bolstering the importance of social support in depression (Harris, Brown, and Robinson 1999).

Temperamental factors have been found to increase people's risk for developing depression. For instance, there is a great deal of evidence linking neuroticism to depression (e.g., Duggan et al. 1995; Kendler et al. 1993). In fact, high levels of neuroticism have been found not only to be associated with current depression, but also to persist in people following recovery from their depressions. Some investigators have drawn on these data to suggest that neuroticism may be present prior to the first onset of depression, and may represent a vulnerability marker or risk factor for developing depression (Duggan et al. 1995).

Finally, there may be specific patterns of thinking that elevate people's risk for the development of depression. Research has demonstrated that certain cognitions or cognitive styles are strongly related to depression. For example, according to the reformulated learned helplessness model (Abramson, Seligman, and Teasdale 1978), people who believe that negative events result from stable, global, and internal factors are more likely to become depressed than are individuals who do not hold these views. For instance, if a person believes that he failed a math test because he is bad at math, rather than attributing the failure to the difficulty of the test or his having had a bad day, then he is attributing his failure to an internal factor. If he then says that he is bad at school more generally and has always been, then he is making stable and global attributions as well, putting him, according to this model, at increased risk for becoming depressed. Similarly, Aaron Beck (1976) has posited that individuals who attend to negative stimuli more readily than to positive stimuli, and who have dysfunctional beliefs about loss and failure (e.g. that others never fail, or that they should never fail), are also likely to become depressed. Although these negative cognitive styles may be longstanding and appear to be a part of someone's personality, it is still unclear whether these cognitive patterns cause depression, are a consequence of depression, or have a more complex relationship to this disorder (Gotlib and Abramson 1999).


Depression and Interpersonal Relationships

Depression in adults can often have a negative impact on interpersonal relationships. Depressed people evaluate their social skills negatively, reporting that they do not enjoy, and are not very adept at, socializing (Davis 1982; Lewinsohn et al. 1980). Independent observers have documented that depressed people have fewer social skills than nondepressed individuals (Segrin 2000). The relationships of depressed people are often characterized by low intimacy, poor communication, and withdrawal, characteristics that may lead to rejections and disappointments. Indeed, depression in individuals can lead others around them to feel irritability, anger, and fatigue; depressed people have been found to exhibit a high level of dependency on others, or to withdraw from others, both of which can put a strain on interpersonal relationships.

Late-twentieth-century research indicates that depression also adversely affects the quality of relationships with spouses and children. For example, investigators have found the interactions of married couples in which one spouse is depressed to be characterized by less cooperation and more angry exchanges than is the case among couples in which neither spouse is depressed (Davila 2001; Goldman and Haaga 1995). Not surprisingly, depression in marriage has been shown to be strongly associated with distress and disruptions in marital relationships; indeed, the rate of divorce among individuals who have experienced clinical depression is significantly higher than is the case among nondepressed individuals (e.g., Wade and Cairney 2000).

Given the high level of marital distress and discord associated with depression, it is not surprising to learn that the children of depressed parents have themselves been found to exhibit greater emotional and somatic symptomatology, and to have more school, behavioral, and social problems, than have children of nondepressed parents. Children of depressed parents have also been found to be at elevated risk for developing psychopathology (see Gotlib and Goodman 1999, for a review of these literatures). Several lines of research have emerged trying to understand the mechanisms underlying the elevated levels of psychopathology among children of depressed parents (Goodman and Gotlib 1999). Whereas a number of investigators have examined the genetic transmission of risk for depression from parent to child (e.g., Wallace, Schneider, and McGuffin 2002), other researchers have focused on aspects of the relationships between depressed parents and their children. For example, when they are depressed, adults are less effective at disciplining their children and are more likely to exhibit frustration and anger or withdraw and behave in a rejecting manner when they cannot achieve their desired outcomes with their children. Children of depressed parents may also model their parent's behavior and either act out and exhibit anger, or become isolated and withdrawn. They may feel unloved and find that they only get attention when they misbehave, which will tend to increase the amount of misbehavior. Depressed parents may come to rely to heavily on their children to perform tasks that they have become unable to carry out. Depressed parents may also rely too heavily on their children for emotional support when their marital relationship becomes strained. In this context, a depressed parent may share information that a child is unable to handle emotionally, such as thoughts of suicide or hopelessness.


Treatment of Depression

Depression is a treatable disorder. Because there are a variety of methods for treating depression, people who experience depression have several choices with respect to the type of treatment they choose to undertake. Treatments that focus on the depressed individual alone include pharmacotherapy (e.g., antidepressant medication) and psychotherapy (e.g., cognitive therapy, behavior therapy, or social skills training). Depressed people who are married may choose from these individual approaches to treatment, or they may undertake marital or family therapy for depression. Regardless of which form of treatment a depressed person chooses, it is important that the treatment has been demonstrated empirically to be effective in reducing depressive symptoms.

Although it may seem counterintuitive to treat marital problems in order to alleviate depression, there is evidence in support of the efficacy of this type of treatment, particularly in distressed marriages. Indeed, there are several different forms of marital and family therapy that are effective in the treatment of depression. For example, in maritally distressed couples, marital therapy has been found to be effective in treating depression in the context of marriage. K. Daniel O'Leary, Lawrence Riso, and Steven Beach (1990) asked wives in distressed marriages to identify which came first, the marital problems or their depression. In couples who reported that marital discord preceded the onset of depression, the wives reported that the marital distress was an important cause of their depression. This raised the possibility that marital therapy would be a way of targeting the perceived causes for depression. In fact, studies have demonstrated that marital therapy is as effective as individual cognitive-behavioral therapy in alleviating depressive symptoms of spouses in distressed marriages. Moreover, patients receiving marital therapy have been found to report higher marital satisfaction than do patients receiving cognitive-behavior therapy (Jacobson et al. 1991; O'Leary and Beach 1990). Steven Beach, Mark Whisman, and K. Daniel O'Leary (1994) suggest that behavioral marital therapy is an effective intervention for a specific subgroup of married depressed patients.


Interpersonal therapy (IPT) for depression usually takes approximately twelve weeks and also focuses on the current marital distress. Although IPT bears some relationship to psychodynamic treatments that preceded it, its focus is different. Instead of dealing with past conflicts and unconscious material, this treatment emphasizes current problems and concerns. This form of treatment was adapted in the late twentieth century to work with geriatric populations by including certain kinds of concrete help in the treatment (e.g., obtaining transportation for the patient to attend sessions), flexibility in the length of sessions, and acknowledging the different life circumstances of older adults that may make some solutions less feasible or desirable (e.g., divorce after a long marriage; see Gotlib and Schraedley 2000 for a review of IPT for depression).

Another form of treatment for depression that has an interpersonal focus is behavioral family therapy. Like interpersonal therapy, behavioral treatment focuses on current problems. Behavioral treatment emphasizes concrete and specific behavior changes, along with skills training as needed. Early in the treatment, families in which a member is depressed are educated about depression's symptoms and consequences. The therapist underscores both the legitimacy of the disorder and the importance of treatment compliance, both for the person suffering from depression and for the family. In addition, families are taught better communication skills, including how to compromise, negotiate, manage anger, constructively express feelings, and listen empathically. Families are also provided with problem-solving skills training, and learn to concretely define their goals and generate more solutions to achieve those goals.

Finally, cognitive-behavioral family therapy has also been found to be effective in the treatment of depression. As with behavioral treatment, cognitive-behavioral family therapy also offers skills training in communication and problem solving as needed. In addition, the therapist models appropriate behavior: for example, parental discipline as part of skills training in parenting. Here, too, the focus is on current problems and concerns. Although cognitive-behavioral treatment is similar to behavioral therapy in its emphasis on current behavior and training of skills, this form of treatment is based on the notion that people's thoughts about events and actions lead them to make specific attributions about the event or action. This process may lead them to have overly negative expectations of their relationships and interpersonal interactions. Individuals with these negative cognitive schemas are also believed to filter their experience through the lens of their expectations, perceiving more of their interactions as negative than is actually the case. One of the therapist's primary tasks is to help the family identify attributions and the irrational beliefs that underlie them. The therapist demonstrates to the family how these thoughts and beliefs can affect their behavior and the behavior of those with whom they come into contact. Once the therapist has elucidated the relationship between the cognitions and behavior, cognitive restructuring can begin. Cognitive restructuring involves the therapist helping the family to understand the irrationality of the original maladaptive cognitions. According to cognitive-behavioral theory, by changing people's attitudes and beliefs, cognitive restructuring leads to behavior change.


Depression and Culture

Depression is a heterogeneous condition that may call for different types of treatment depending on the specific marital context in which the depressed person lives. Depression also occurs, of course, in many different cultural contexts. As with any disorder, depression can interact with culture and values; consequently, treatments need to be culturally sensitive and aware. Moreover, these different values mean that specific treatments or recommendations may be more useful and effective in some groups and, in fact, may even be contraindicated in others. For example, in African-American families, there is generally less of an emphasis on culturally defined gender roles than is the case in Caucasian families. Employment for women from African-American families has been found to be helpful to these women and their families, whereas employment showed fewer benefits for Caucasian women and their families, at least among older adults (Cochran, Brown, and MacGregor 1999). Therefore, clinicians may find that helping African-American women gain access to employment opportunities would be a useful intervention, whereas Caucasian women may receive fewer benefits from such help.

In Asian cultures, in which there is a greater focus on the interdependence of family members and connection with other people within the larger culture, depression may manifest in different ways than in the West and may therefore respond to different types of treatment. Because of Asians' greater cultural emphasis on social connection, what are viewed as symptoms of depression in the West may be interpreted more as interpersonal difficulties in these cultures. In addition, Asians may focus more on somatic difficulties than on emotional symptoms, perhaps in part because they make fewer mind/body distinctions in their culture than do Westerners. Therefore, "depression" in those cultures may be expressed and experienced more through physical than emotional symptoms. This may also be related to the fact that emotional problems are typically viewed as more stigmatizing in Asian cultures than they are in the West. Because of this greater stigma, Western treatments of discussing feelings and troubles are often contraindicated with Asian patients because this may exacerbate emotional pain and the shame, rather than alleviating suffering. Finally, Asians generally experience greater family and social connections and support than do people in Western cultures. This seems to be somewhat protective against depression and rates of depression in Asian countries such as Japan, China, and Taiwan are lower than in the Western world.

Latin/Hispanic cultures also place a greater emphasis on family than do many other Western cultures. Although the social support from family is protective, poverty and lack of resources continue to plague many Latino communities. Latino families living in the United States may find themselves relatively isolated from American culture and opportunities and, consequently, at greater risk for depression and other difficulties. Given the findings that lower acculturation is associated with more depression (e.g., Hovey 2000), it would seem important to aid less assimilated families in accessing resources and finding ways to become acculturated while maintaining their original cultural identity. In addition, it is crucial that clinicians attempt to remove the linguistic, cultural, and practical barriers to treatment faced by many minority populations. Finally, clinicians need to be sufficiently culturally knowledgeable to understand certain symptoms in context. For example, in Puerto Rican culture, dissociative states may be a normal part of spiritual practice, though these states would generally be considered psychopathological in mainstream U.S. culture (Tsai et al. 2001). Clinicians who can recognize culturally normative practices and differentiate them from pathology, and who develop culturally appropriate treatments, will be the most likely to be successful in alleviating their patients' distress.


See also:Children of Alcoholics; Chronic Illness; Depression: Children and Adolescents; Development: Self; Developmental Psychopathology; Grief, Loss, and Bereavement; Health and Families; Postpartum Depression; Power: Marital Relationships; Self-Esteem; Stress; Suicide; Therapy: Couple Relationships


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ian h. gotlib
karen l. kasch


CHILDREN AND ADOLESCENTS


The sadness that characterizes depression is similar at all ages but is most upsetting to adults when observed in children. Depression is characterized by feelings of sadness, fatigue, and a general lack of enthusiasm about life. It can be of short or long duration, of low or high intensity, and can occur at any stage of development. Up until the 1970s there was considerable disagreement about whether depression could occur before the onset of formal operational thought, a cognitive ability that emerges in adolescence. Later debates have shifted to determining the specific age at which children are able to identify and label feelings related to depression, and recent findings suggest that by five or six years of age children are capable of doing so (Ialongo, Edelsohn, and Kellam 2001). The use of parent reports has allowed for the identification of depressive disorders among preschoolers, and additional work has focused on identifying young children who are at risk for depression because they have one or more relatives with a mood disorder (Cicchetti and Toth 1998).


Depression Classifications

The classification and investigation of depression typically focuses on: depressed mood, depressive syndromes, or clinical depression (or depressive disorders). Each approach reflects differences in assumptions concerning the nature of depression and denotes different levels of depressive phenomena (Petersen et al. 1993; Cicchetti and Toth 1998).


Depressed mood. Research on depressed mood has focused on depression as a symptom denoted by feelings of sadness, unhappiness, or the blues lasting for an unspecified period of time. It is differentiated from normal sadness by the absence of positive affect, a loss of emotional involvement with other persons, objects, and activities, and negative thoughts about oneself and the future (Fombonne 1995). Self-report measures are most often used with older children and adolescents; parent and/or teacher reports are typically used for younger children.

Depressed mood occurs in about one-third of all youth at any point in time, and ranges from 15 to 45 percent among adolescent samples. Results from the few studies that have charted depressed mood across the adolescent years suggest that it peaks around the ages of fourteen and fifteen and then attenuates slightly (Petersen, Sarigiani, and Kennedy 1991). Reliable gender differences do not exist until adolescence, when girls are more likely to experience depressed mood than boys.


Depressive syndromes. Depressive syndromes involve sets of symptoms that have been shown to occur together. Behavior problem checklists, completed either by children/adolescents or parents/teachers, are the main source of identification. These checklists usually include either severity or frequency ratings and consist of items such as sadness, moodiness, sleep disturbances, feelings of worthlessness, guilt, and loneliness. Most research examining depressive syndromes has used a cutoff score corresponding to the ninety-fifth percentile in nationally representative samples. In comparing the mean scores on the Anxious/Depressed Syndrome of the Child Behavior Checklist across twelve cultures (ages ranged from six to seventeen years), Alfons Crijnen and colleagues (1999) found Germany, the Netherlands, Sweden, and Thailand to be lower on average, whereas Greece, Israel, Puerto Rico, and the United States were above average, with Australia, Jamaica, Belgium, and China being average. Girls obtained higher scores than boys across all cultures.

Clinical depression. Clinical depression is more severe and lasts longer than depressive mood or syndromes and has a major impact on daily living. Clinical depression is identified by categorical diagnoses, such as those described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994) or the International Classification of Diseases (ICD-10) (World Health Organization 1996). Most often these diagnoses are made through individual interviews with a clinical psychologist. According to the DSM-IV, two forms of depression have been identified: Major Depressive Disorder (MDD) and Dysthymic Disorder (DD).


The diagnosis of MDD requires the presence of at least five of nine symptoms during the same two-week period, with one of the symptoms being depressed mood (dysphoria) for most of the day nearly every day or loss of interest and pleasure (Kolvin and Sadowski 2001). Irritable mood in children and adolescents may be substituted for depressed mood. The other possible symptoms include: significant weight change (in children, the failure to make expected weight gains), insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, diminished ability to concentrate or indecisiveness, and recurrent thoughts of death, suicidal ideation, or suicide attempt. The symptoms are not due to direct psychological effects of a substance, a general medical condition, or bereavement. An episode of MDD in children lasts, on average, about eleven months, with recovery generally taking about seven to nine months (Kovacs and Sherill 2001). Estimates of the point prevalence of MDD range from 0.4 to 2.5 percent for children and from 0.4 to 8.3 percent for adolescents (Birmaher et al. 1996; Verhulst et al. 1997). The estimated lifetime prevalence of MDD for adolescents is 15 to 20 percent, a rate comparable to that for adults (Harrington, Rutter, and Fombonne 1996).

The diagnosis of DD requires the experience of depressed mood for most of the day, for most days for at least two years (Kolvin and Sadowski 2001). For children and adolescents irritable mood and a duration of at least one year are allowed as alternative criteria. Two of six additional symptoms (poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, poor self-esteem, difficulty concentrating or making decisions, and feelings of hopelessness) are also required.

There appears to be a trend for both an increased rate of depression across generations, and an earlier onset of major depressive disorder, with more onsets occurring during adolescence than previously (Fombonne 1995). A recent review of the gender differences in rate of clinical depression concluded that prior to puberty boys are anywhere from two to five times more likely to exhibit depression than are girls, whereas after age thirteen this difference shifts to girls with depression occurring at least twice as frequently in girls and women as in boys and men (Angold and Costello 2001)

Additional co-occurring problems with depression. Studies on both community and clinical samples report that anywhere from 7 to 51 percent of depressed children and adolescents have multiple psychiatric disorders, with anxiety and conduct or disruptive behavior disorders as the most common co-occurring disorders (Kovacs and Sherrill 2001). Anxiety disorders often precede depressive conditions. Eating disorders and drug and alcohol use often co-occur with depressive symptoms. Adolescents with affective disorders have a higher than normal risk of suicide.


Causes

There is no single cause for depression and any single risk factor rarely results in depressive outcomes. Rather, the structure of biological, psychological, and social systems over an individual's development need to be considered (Cicchetti and Toth 1998).

Heredity. Although there is no conclusive evidence that there exists a specific, single gene for depression, there is evidence that some families have an inherited vulnerability to depression. Close relatives of depressed people have a 15 percent chance of inheriting major depression. An identical twin with a depressed twin is 67 percent more likely to be depressed. A child having one depressed parent is six times more likely to develop depression than a child without a depressed parent and the risk for a child to develop depression increases to 40 percent if both parents are depressed. The parents and extended family members of depressed children are not only more likely to exhibit a higher incidence of depression but also found to have higher levels of anxiety, substance abuse, and antisocial behavior (Cicchetti and Toth 1998). Although this association is partially a result of heredity, the environment that family members share also contributes to depressive symptoms (Rende et al. 1993). The fact that many depressed children promptly recover when hospitalized, even when no other treatments are administered, lends additional credence to the role the family may play in a child's depression (Cicchetti and Toth 1998). Additionally, relapse of depression after being released from in-patient psychiatric care is confined primarily to children who return home to an environment characterized by high emotional overinvolvement, criticism, and hostility (Asarnow et al. 1993).

Parental depression. As noted above, children having one or two clinically depressed parents are more vulnerable to developing depression than children without a depressed parent. In addition, more severe and chronic parental depression is associated with greater impairment in children (Goodyer 2001). Several possible mechanisms for the increased vulnerability to depression for children of depressed parents, besides direct hereditary transmission of depression, have been proposed. Most research in this regard has focused on mothers and how they interact with their children, although more recent work is including fathers. A parent struggling with his or her own depression may not be able to provide adequate responsiveness and care to children as the depression may interfere with the ability to react flexibly and creatively to the normative challenges that parenting entails (Kaslow, Deering, and Racusin 1994). Children of depressed mothers are at greater risk for an insecure attachment and for disruptions in emotional regulation (Cicchetti and Toth 1998; McCauley, Pavlidis, and Kendell 2001), which, in turn, increases a child's vulnerability for depression. Compared to nondepressed mothers, depressed mothers are more likely to use withdrawal, conflict avoidance, or overcontrolling strategies rather than negotiation to cope with child noncompliance (McCauley, Pavlidis, and Kendell 2001). Depressed mothers and fathers tend to be more hostile and irritable when interacting with their children, and the marital relationship itself often is characterized as dysfunctional and conflictive. Moreover, families with a depressed parent experience increased and persistent stressors, further taxing a parent's ability to cope constructively. Hence, not only is child nurturance disrupted but also a depressed parent serves as a role model for depressive thinking (McCauley, Pavlidis, and Kendell 2001). Moreover, the child becomes increasingly exposed to stressful life events that are not under his or her control, further increasing vulnerability to feelings of helplessness, hopelessness, and depression. Thus, children of depressed parents are at increased hereditary risk for depression, are more likely to experience disruptions in both physical and emotional relations with parents, have parental role models for depressive thinking, and are more likely to experience stressful life events and conflict. Together these findings underscore how children of depressed parents are exposed to a variety of risk factors that increase their vulnerability for depression.

Family context. Compared to families of nondepressed children, families of depressed youth have higher levels of marital and parent-child conflict, low levels of family cohesion, and diminished overall social support. Regardless of ethnicity, social class, or parents' marital status, parents who are accepting, firm, and democratic have adolescents who report less depression (Steinberg et al. 1991; Herman-Stahl and Petersen 1996). Longitudinal studies have also demonstrated that adolescents with warm family relations are less likely to become depressed several years later (Petersen, Sarigiani, and Kennedy 1991).

Dante Cicchetti and Sheree Toth (1998) propose that a vulnerability to depression may begin in infancy if there is an insecure attachment to primary caretakers. Infants who are insecurely attached are more likely to have less than optimal emotional regulation and expression, and as these infants grow into young children significant others are perceived as unavailable or rejecting while the self is perceived as unlovable. These perceptions may contribute to a proneness to self-processes that have been linked to depression (e.g., low self-esteem, helplessness, hopelessness, and negative attributional biases). When combined with additional environmental stressors these self-processes may contribute to a modification of hormonal and brain processes that further increase vulnerability.

Brain and hormonal processes. Research on biological disregulation during depression focuses on the hypothalamic-endocrine and neurotransmitter systems. As noted in the Surgeon General's report on mental health (1999), some of the primary symptoms of depression, such as changes in sleep patterns and appetite, are related to functions of the hypothalamus. The hypothalamus, in turn, is closely linked to the pituitary gland. Increased rates of circulating cortisol and hypo- and hyperthyroidism, each associated with pituitary function, are established features of adult depression. Research on the hypothalamic-endocrine link involved in childhood and adolescent depression focuses on the hypothalamic-pituitary-adrenal (HPA), hypothalamic-pituitary-gonadal (HPG), and hypothalamic-pituitary-somatotropic (HPS) axes, all of which are related to growth processes and pubertal change (Brooks-Gunn, Auth, Petersen, and Compas 2001). In each of these axes the hypothalamus secretes a releasing hormone that triggers the pituitary to release a stimulating hormone, which, in turn, then stimulates the secretion of an additional hormone by the particular gland in question (adrenal, gonadal, thyroid). This hormone is then released into circulation, inhibiting the hypothalamus and pituitary to produce more releasing and stimulating hormones (Brooks-Gunn et al. 2001). Variations from normal patterns of coritsol and dehydroepiandrosterone (both from the HPA axis), prolactin (from the HPG), and growth hormone (from the HPS axis), have been observed among depressed children and adolescents (Dahl et al. 2000; Schulz and Remschmidt 2001).

At the neurotransmitter level, differences in serotogenic, cholinergic, noradrenic, and dopaminergic systems have all been associated with depression (Brooks-Gunn et al. 2001; Sokolov and Kutcher 2001). Whereas early research focused on deficiencies or excesses in neurotransmitter substances, current research now focuses on the functioning of the neurotransmitter systems with respect to the storage, release, reuptake, and responsiveness (Sokolov and Kutcher 2001). New research is examining the interaction between the hypothalamic-endocrine and neurotransmitter systems. However, as noted by Jeanne Brooks-Gunn and her colleagues (2001), less certain is whether changes and deficits in these systems are causes, correlates, or a result of depression. Nevertheless, once a depressive episode occurs, biological disregulation follows, further influencing behavior, thought, mood, and physiological patterns.

Cognitive factors. Attributional bias and coping skills are the two main cognitive factors investigated with respect to understanding depression. Considerable research has focused on the pessimistic attributional biases that are prevalent among depressed adults. A person with this bias readily assumes personal blame for negative events, expects that one bad experience will be followed by another, and that this pattern will endure permanently. Individuals who think this way have a tendency to cope with situations more passively and ineffectively than those without this bias. Among children, this attributional style is related to depression after the age of eight years; prior to this, childhood depression is primarily linked to negative life events (Nolen-Hoeksma, Girgus, and Seligman 1991).

Adaptive coping skills are important in order to regulate negative emotions when unpleasant and challenging events occur. Problem-focused coping refers to how an individual responds to the demands of a stressful situation in terms of active efforts to do something about the problem. Emotion-focused coping, in contrast, refers to the individual's attempts to control the emotion experienced. One form of emotion-focused coping is rumination: the tendency to focus repetitively on feelings of depression and their possible causes without taking any actions to relieve them. Another form is avoidant coping: the tendency to withdraw from or avoid stressors or to deny their existence. Emotion-focused coping such as rumination and avoidant coping have been linked to depression in adults, adolescents, and children (Herman-Stahl and Petersen 1999; Nolen-Hoeksma 1998).


Gender Differences

Most theories concerning gender differences have focused on explaining the female preponderance during adolescence and adulthood. Males and females appear to have different coping styles: males distract themselves, whereas females ruminate on their depressed mood and therefore amplify it (Nolen-Hoeksma 1998). Most young adolescents are faced with significant changes in every aspect of their lives: pubertal development, cognitive maturation, school transition, and increased performance pressures in academics. For many adolescents these events are stressful. Girls experience more challenges during adolescence compared to boys, including more negative life events, simultaneous changes in pubertal development and school transitions, making them more vulnerable to depression (Petersen, Sarigiani, and Kennedy 1991). Not only are differences in challenges and coping important but the hormonal changes that accompany pubertal development may also make girls more vulnerable (Angold, Costello, and Worthman 1998). Thus, it now appears that a combination of factors, including less effective coping styles, more challenges, and hormonal changes, may help to explain the gender differences in depression during adolescence.

Treatment

Treatments for depression in children and adolescents generally include three forms: pharmacological, psychotherapy, and a combination of the two. Unlike studies on adults, methodologically sound investigations on the relative effectiveness of each type of therapy on youth are only just beginning to be conducted. Thus, most findings are based on a few studies and therefore need to be interpreted cautiously.

Pharmacological. The drugs most commonly used for treating depression in children and adolescents are available in three major types: the monoamine oxidase inhibitors (including phenelzine and tranylcypromine), the tricyclic antidepressants (including lofepramine, imipramine, and nortriptyline) and the recently developed selective serotonin and serotonin-noradrenergic re-uptake inhibitors (including fluoxetine, paroxetine and venlafaxine) (Schulz and Remschmidt 2001). Although virtually all medications found to be effective for adult depression have been tested with children, systematic studies with clear results are rare, and superiority of antidepressant medication over placebos for children and adolescents has not been reliably demonstrated (Kovacs and Sherrill 2001; Schulz and Remschmidt 2001). Therefore, antidepressant medications should only be prescribed for children and adolescents when: symptoms are so severe that they prevent effective psychotherapy; symptoms fail to respond to psychotherapy; and the depression is either chronic/recurrent, nonrapid bipolar, or psychotic (Schulz and Remschmidt 2001). Selective re-uptake inhibitors are the initial antidepressant of choice, although the presence of other symptoms such as impulsivity, suicide, or attention deficit hyperactivity disorder (ADHD) may require alternative medications (Schulz and Remschmidt 2001).

Psychotherapy. Studies of psychosocial interventions for depression among youngsters have traditionally included clinically diagnosed children, children classified as having a depressive syndrome, or youngsters deemed at risk for depression based on elevated scores on depressive symptom checklists. Controlled psychotherapy trials on clinically depressed youth typically include short-term cognitive behavioral therapy (CBT) delivered in individual or group format (Kovacs and Sherrill 2001). Cognitive behavioral therapy is based on the premise that depressed individuals have distortions in thinking concerning themselves, the world, and their future. Thus, therapy focuses on changing or preventing these distortions (cognitive restructuring), and also includes training in social skills, assertiveness, relaxation, and coping skills. Of the seven clinical studies reported to date, 35 to 90 percent of the youths recovered, with higher rates of success for experimental therapies than the control conditions (Kovacs and Sherrill 2001). Although only two studies included a parent component as part of the treatment condition, including the parent component did not improve outcomes. Interventions targeted at nonclinical but at-risk youth identified in school settings have had even more favorable results. Seven of eight studies reported decreases in depressed mood and syndromes. One demonstrated long-term effects of the intervention in reducing the likelihood for developing clinical levels of depression. These promising results highlight the beneficial effects of early identification and prevention efforts. Additional studies are needed to clarify how parents and other family members may be included in treatment programs.

According to Maria Kovacs and Joel Sherrill (2001), clinically referred depressed youth usually experience a disruption to the parent-child relationship. Because depressed children and adolescents are either unwilling or unable to verbalize their affective experience, parents, in turn, may withhold emotional support, guidance, and expressions of affection. Based on their work and that of others, Kovacs and Sherrill suggest that the most appropriate treatment of depressed juveniles should include structured, goal-directed, or problem-solving oriented interventions that focus on symptom reduction, enhancement of self-esteem, and social/interpersonal skill development. In addition, involvement of the parents or primary caretakers is essential and should occur at two levels. First, parents should be assessed to determine if they themselves suffer from a form of emotional or mental disorder. Those who are positively identified should receive treatment. Second, parents should be engaged as agents of change in treatment of their own children, including some sessions explicitly focused on the depressed child's needs and concerns.

See also:Attachment: Parent-Child Relationships; Child Abuse: Physical Abuse and Neglect; Child Abuse: Psychological Maltreatment; Child Abuse: Sexual Abuse; Childhood, Stages of: Adolescence; Children of Alcoholics; Chronic Illness; Conduct Disorder; Depression: Adults; Development: Self; Developmental Psychopathology; Grief, Loss, and Bereavement; Eating Disorders; Health and Families; Interparental Conflict— Effects on Children; Interparental Violence—Effects on Children; Self-Esteem; Stress; Suicide


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judith semon dubas anne c. petersen

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Depression

Depression

Definition

Depression, also known as depressive disorders or unipolar depression, is a mental illness 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. However, when these depressed feelings start to dominate everyday life without a recent loss or trauma and cause physical and mental deterioration, they become what is known as depression. Each year in the United States, depression affects 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 1020% lifetime prevalence, compared to 510% 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 depression: 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 in which they once took pleasure, experience a change in weight, have difficulty concentrating, feel worthless and hopeless, or have a preoccupation with death or suicide. In children, 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, nondepressed 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 & symptoms

The causes behind depression are complex and not yet fully understood. While an imbalance of certain neurotransmitters, the chemicals in the brain that transmit messages between nerve cells, is 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, and 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 .

SYMPTOMS OF ADULT DEPRESSION
Longterm sadness
Feelings of worthlessness or guilt
Lack of interest in sex
Loss of concentration
Loss of interest in activities
Fatigue
Weight loss or gain
Insomnia or oversleeping
Anxiety
Suicidal thoughts
Slowed speech and physical movement

Heredity seems to play a role in who develops depression. 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 predisposed or prone to depressive disorders, but environmental circumstances may often 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 suicidal and/or suicide attempts
SYMPTOMS OF CHILDHOOD/ADOLESCENT DEPRESSION
Drop in school performance
Weight loss or gain
Stomachaches
Insomnia
Social withdrawal
Drug or alcohol abuse
Isolation
Apathy
Fatigue
Lack of concentration

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 postcardiac 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
  • altered libido
  • altered appetite
  • altered motivation
  • feelings of hopelessness

Diagnosis

The guidelines for diagnosis of major depressive disorder and dysthymic disorder are found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV ). 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

A variety of alternative medicines have proven to be helpful in treating depression. A recent 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. Chocolate, coffee, sugar, and alcohol can negatively affect mood and should be avoided. Essential fatty acids may reduce depression and boost mood. Expressing thoughts and feelings in a journal is therapeutic. Aromatherapy , particularly citrus fragrance, has had a positive effect on depression. Psychotherapy or counseling is an integral component of treatment because it can find and treat the cause of the depression.

Psychosocial therapy

Psychotherapy explores a person's life to bring forth possible contributing causes of depression. During treatment, the therapist helps the patient to become aware of his or her thinking patterns and how they originated. 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 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 patient to recognize the thinking and react differently to it.

Chinese medicine and herbals

The principle of treatment of depression involves regulating qi, reducing phlegm, calming the mind, and promoting mental resuscitation. The Chinese medicine Bai Jin Wan (White Metal Pill) is used to treat depression (5 g twice daily). A practitioner may prescribe a variety of treatmentsincluding lifestyle changesdepending on the type and severity of the depression.

There is some evidence that acupuncture is a helpful treatment for depression. One double-blind study found that patients who received acupuncture specific for depression were significantly less depressed than control patients who had either nonspecific acupuncture or no treatment.

St. John's wort (Hypericum perforatum ) is the most widely used antidepressant in Germany. Many studies on the effectiveness of St. John's wort have been performed. One review of the studies determined that St. John's wort is superior to placebo and comparable to conventional antidepressants. In early 2000, well designed studies comparing the effectiveness of St. John's wort versus conventional antidepressants in treating depression were underway in the United States. Despite uncertainty concerning its effectiveness, a 2003 report said acceptance of the treatment continues to increase. A poll shoed that about 41% of 15,000 science professionals in 62 countries said they would use St. Johnís 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.

Orthomolecular therapy

Orthomolecular therapy refers to therapy that strives to achieve the optimal chemical environment for the brain. The theory behind this approach is that mental disease is caused by low concentrations of specific chemicals. Linus Pauling believed that mental disease was caused by low concentrations of the B vitamins, biotin, vitamin C , or folic acid . Supplementation with vitamins B1, B2, and B6 improved the symptoms of depression in geriatric patients taking tricyclic antidepressants. The amino acids tryptophan, tyrosine, and phenylalanine have been shown to have positive effects on depression, although large, controlled studies need to be carried out to confirm these findings.

S-ADENOSYL-METHIONINE. 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.

5-HYDROXYTRYPTOPHAN. 5-hydroxytryptophan (5-HT, 5-HTP ) is a precursor to serotonin. Most of the commercially available 5-HT is extracted from the plant Griffonia simplicifolia. In several small studies, treatment with 5-HT significantly improved depression in more than half of the patients. One review of these studies suggests that 5-HT has antidepressant properties, however, large studies must be performed to confirm this finding. The usual dose is 50 mg three times daily. Side effects include nausea and gastrointestinal disturbances.

Homeopathic remedies

Homeopathic remedies can be helpful treatments for depression. A homeopathic practitioner should be consulted for dosages, but common remedies are:

  • Arum metallicum for severe depression
  • Ignatia for adjustment disorder
  • Natrum muriaticum for depression of long duration.

Light therapy

Light therapy is helpful in controlling the depression of seasonal affective disorder (SAD). Treatment consists of exposure to light of a high intensity and/or specific spectra for an hour per day from a light box placed on the floor or on a table. The light intensity is usually 10,000 lux which is similar to the light of a sunny day. The opposite may be used, as well, which is the use of a dawn simulator for those patients who have an overdose of light exposure and require more sleep with less light. Most persons will see an effect within three to four weeks. Side effects include headaches, eye-strain, irritability, and insomnia. A week or more in a sunny climate may improve SAD.

Allopathic treatment

Depression usually is treated with antidepressants and/or psychosocial therapy. When used together correctly, therapy and antidepressants are a powerful treatment plan for the depressed patient.

Drugs

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. A recent study shows this generation of drugs increases patients' risk of gastrointestinal bleeding.

Tricyclic antidepressants (TCAs) are less expensive than SSRIs, but have more severe side effects including 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 (MAO inhibitors), 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 avoid foods high in tyramine (found in aged cheeses and meats) to avoid potentially serious hypertensive side effects.

Heterocyclics include bupropion (Wellbutrin) and trazodone (Desyrel). Bupropion is prescribed to patients with a seizure disorder. Side effects 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, Well-butrin's manufacturer released a once-daily version of the drug that offered low risk of sexual side effects or weight gain.

Electroconvulsive therapy

ECT, or electroconvulsive therapy, usually is employed after all therapy and pharmaceutical treatment options have been explored and exhausted. 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, has also been reported in ECT patients. ECT causes severe memory problems for months or years in one out of every 200 patients treated.

Late in 2001, a study reported on a pacemaker-like device used to treat epilepsy adapted for patients with depression. An implanted electronic device sends intermittent signals to the vagus nerve, which in turn carries the signals to the brain, connecting in areas known to regulate mood. Although still experimental at this time, early results in treating depression have been encouraging.

Expected results

Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 8090% 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.

Overall, recent recommendations from mental health clinicians suggest that the recovery process for patients with depression works best when mental health professionals focus on the whole person behind the disorder. In addition to prescribing medications, they also should address a patient's self-esteem, feeling of control, and determination. They emphasize that patients with depression need a sense of optimism and should be encouraged to seek the support of family members and friends.

Prevention

Patient education in the form of therapy or self-help groups is crucial for training patients with depressive disorders to recognize early 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 with children with depression is effective in halting development of more severe problems.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.

Peightel, James A., Thomas L. Hardie, and David A. Baron. "Complementary/Alternative Therapies in the Treatment of Psychiatric Illnesses." In Complementary/Alternative Medicine: An Evidence Based Approach. John W. Spencer and Joseph J. Jacobs, eds. St. Louis: Mosby, 1999.

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

Ying, Zhou Zhong and Jin Hui De. "Psychiatry and Neurology." In Clinical Manual of Chinese Herbal Medicine and Acupuncture. New York: Churchill Livingston, 1997.

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.

"Antidepression 'Pacemaker' Demonstrates Long-Term Benefits." Medical Devices and Surgical Technology Week. (December 30, 2001): 34.

Deltito, Joseph, and Doris Beyer. "The Scientific, Quasi-scientific and Popular Literature on the Use of St. John's Wort in the Treatment of Depression." Journal of Affective Disorders 51 (1998): 345-351.

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

Head, Kathi. "Conquer Depression Without Drugs." Let's Live 68 (2000): 72+.

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

Miller, Mark D. "Recognizing and Treating Depression in the Elderly." Medscape Mental Health 2, no.3 (1997). http://www.medscape.com.

Miller, Sue. "A Natural Mood Booster." Newsweek (May 5, 1997): 74-5.

"New Depression and Anxiety Treatment Goals Defined." Health and Medicine Week. (December 31, 2001): 24.

Salmans, Sandra. "More on Treatments." Depression: Questions You Have .. Answers You Need (1997): 145+.

Sansone, Randy A. and Lori A. Sansone. "Dysthymic Disorder: The Chronic Depression." American Family Physician 53, no. 8 (June 1996): 2588-96.

"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 (APA). Office of Public Affairs, 1400 K Street NW, Washington, DC 20005. (202) 682-6119. http://www.psych.org/.

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

National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, Suite 1015, Arlington, VA 22203-3754. (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 (NIMH). 5600 Fishers Lane, Rm. 7C-02, Bethesda, MD 20857. (301) 443-4513. http://www.nimh.nih.gov/.

Belinda Rowland

Teresa G. Odle

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Rowland, Belinda; Odle, Teresa. "Depression." Gale Encyclopedia of Alternative Medicine. 2005. Encyclopedia.com. 1 Jul. 2016 <http://www.encyclopedia.com>.

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Rowland, Belinda; Odle, Teresa. "Depression." Gale Encyclopedia of Alternative Medicine. 2005. Retrieved July 01, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3435100255.html

Depression

Depression

Description

Everybody feels sad sometimes, but to be clinically depressed is not just a matter of feeling sad. A patient with cancer is diagnosed as having major depression only if certain symptoms, such as loss of pleasure or thoughts of death, are present for at least two weeks. Only a healthcare professional can accurately determine whether a patient is depressed or is simply upset because of the disease.

A note on depression and children with cancer

Few children with cancer experience depression. For many children survivors of cancer, the experience of having had cancer makes them deeper, more understanding human beings later in adulthood and old age. However, some children with cancer do experience depression, sleep problems, and relationship problems. Depression appearing in a child who has cancer should be treated by a healthcare professional.

The symptoms of depression in children are somewhat different from those in adults. The physician should be notified of a sad mood (or, in children less than six years of age, a facial expression that appears to express sadness) that continues for at least two weeks and is accompanied by at least four of the following: (a) appetite changes, (b) sleep problems or excessive sleep, (c) excessive activity or inactivity, (d) loss of pleasure, (e) not caring about anything, (f) fatigue, (g) being overly critical of himself or herself, (h) feeling worthless or guilty for no apparent reason, (i) inability to concentrate, and (j) thoughts of death.

Are most people who have cancer depressed?

Most people who have cancer are not depressed. Depression is found in cancer patients about as frequently as in patients hospitalized for major, noncancer illnesses such as heart disease. However, depression is more often present in people who have cancer than in the general population. Approximately one out of eight people with cancer are depressed. Among hospitalized people with cancer, roughly one in four is depressed.

Depression and embarrassment

Doctors and nurses can do a great deal to help a depressed person feel better. Being embarrassed can get in the way of the patient's getting help. While depression is a disease that happens to a minority of cancer patients, it does appear in a sizable number of these patients. Doctors and nurses are trained to deal with depression in cancer patients. If one out of eight people with cancer are depressed, it is no surprise to healthcare professionals that some patients require treatment for depression. It is not "bothering" a good health care professional to let them know that the patient is experiencing some symptoms that may signal depression. Competent doctors and nurses will not think less of a patient who is depressed. Rather, they will respect the patient who acknowledges the willingness to seek and accept treatment for depression. Cooperative patients are not those who hide depression but those who deal with depression when it appears. Dealing honestly and with the aid of doctors and allied healthcare professionals is the right way to address any cancer-related symptom.

How does depression affect someone who has cancer?

Depression is not something that can be pointed to, as one would point to a runny nose or an earache. That does not mean it is not real, nor does it mean the depression does not have a major effect on the cancer patient. The fact is that depression may not only affect what patients can do and how they feel, depression may also affect how well they function and how long they live.

A study of patients with acute leukemia who were receiving bone marrow transplantation found that those who were not depressed lived longer. A study of breast cancer patients showed that depression can be treated successfully and life extended. In this study, women with metastatic breast cancer who joined a support group lived twice as long as matched patients who did not join a support group. In light of these types of studies it would be incorrect to assume that depressed cancer patients who work with their doctors and nurses to treat their depression do not live as long as patients without depression.

Untreated depression or inadequately treated depression may slow recovery time. A study of depressed colorectal cancer patients found they were not able to function as well six months after surgery as patients who were not depressed. Another study found that breast cancer patients who were more anxious and depressed felt more pain than those who were not. Other studies have also shown that depression affects how people function and cope with illness.

Causes

It is certainly understandable that someone with a serious illness feels sad. Many cancer patients are confronted with difficulties. These may include having to take medications, dealing with the side effects of these medications, undergoing operations, submitting to other medical procedures, and generally taking time away from other things they would prefer to do. In addition, many patients feel a sense of loss. They may feel a loss of good health; there may be a loss of part of the body, such as a segment of a breast; there may be a loss of the ability to do certain tasks. There may also be financial strains. Any such things are difficult for most people to deal with. It takes time and effort, and sometimes medical intervention, for people to deal with such loss and gradually get their lives back on track.

If patients are in pain it is extremely important that the pain be adequately treated. Pain is often under-treated. When pain is not treated appropriately, patients may be more likely to develop depression.

Patients with cancer of the pancreas are particularly likely to become depressed. In addition, patients with breast, colon, gynecologic, oropharyngeal, and stomach cancer are more likely to experience depression than patients with other types of cancers. No one knows why depression is more likely to be associated with these cancers.

Approximately one out of every four patients with depression associated with cancer already was depressed at the time of diagnosis. In contrast, approximately three out of four develop the depression after the diagnosis has been made.

Risk factors for depression among cancer patients

Anyone can become depressed, and this includes people with cancer and people who are perfectly healthy. Often, there is no way of predicting who will develop major depression. However, some groups of cancer patients are more likely to develop depression than are others. This include patients who:

  • are younger
  • have a personal or family history of depression or other mental health problems
  • have a personal or family history of substance abuse
  • have body image problems
  • are hospitalized
  • are experiencing unrelieved cancer-related symptoms, such as pain
  • have advanced or relapsed cancer, or have experienced a treatment failure
  • have been diagnosed with stroke or with Parkinson's disease

In addition, some patients are receiving medicines that may cause depression as a side effect. Among these medicines are certain anticancer drugs, antihistamines, blood pressure medicines, anti-Parkinson's disease medicines, medications for convulsions, sedatives, steroids, stimulants, and tranquilizers.

Signs and symptoms

A patient with cancer is diagnosed as having major depression only if certain symptoms are present for at least two weeks. Among these symptoms are:(a) loss of pleasure or interest in activities, (b) major weight loss or weight gain not associated with dieting, (c) serious sleep problems, (d) loss of energy, (e) fatigue , (f) feeling worthless, (g) feeling guilty without adequate reason, (h) problems concentrating, (i) indecisiveness, (j) thoughts of death or suicide. Symptoms such as sleep problems, fatigue, and weight loss may, however, affect cancer patients who are not depressed in the slightest. So, the diagnosis must be made by a healthcare professional.

Often depression appears gradually. At first, the patient seems no more than sad. At times, the person who is in a very early stage of depression brightens up. For many people things never get worse than this and true depression never touches them. However, other people progress to where negative thoughts have a grip upon them.

Gradually, some of the neurotransmitters in the nervous system may stop working in the most healthy way. Neurotransmitters are the chemicals released by nerves to communicate with other nerves. Once a patient's neurotransmitters are affected, the depression is definitely not simply happening in the patient's mind. The way the body uses actual chemicals is being altered by the depressive disease.

Precisely how the depression shows itself may differ from patient to patient. For example, some patients start to respond to little setbacks as though these are catastrophes. Other patients start making big assumptions, usually in negative directions; for example, they may assume their current therapy will not help them, even although there is good medical evidence that it probably will. For yet another example, they may blame themselves for having cancer, or irrationally see the cancer as a punishment visited upon them for something they have done. Patients may try to be too perfect and repeatedly fail. They may think other people have negative feelings about them, or they may focus upon the negative portions of situations. One danger is that the looming depression may encourage patients to push away and alienate those health professionals, friends, and family members who are trying to be helpful. For a final example, a depressed patient may deny the seriousness of the cancer, saying something like, "The tumor is small so I don't really need to be careful about taking my medicines."

Some patients experience a milder form of depression, called dysthymia. Symptoms of dysthymia include annoyance, feelings of sadness, irritability, loss of pleasure, and self-criticism. The patient with dysthymia may develop aches and pains, express excessive guilt, and distance themselves from loved ones. Dysthymia may be almost unnoticeable; however, many patients with dysthymia are unable to function quite as well as they can when they are healthy.

Depression screens

The attending doctor or nurse may request that the patient complete a depression screen. This screen is nothing more than a page or two of questions about how the patient is feeling. The patient's responses give healthcare professionals a picture of whether or not depression may be present.

Prevention

It is important for patients to have an idea of the psychological and social stressors they may have to address because of the cancer. Knowing in advance that something may be a problem is a good way of making sure that it is not quite as stressful once it does appear as it otherwise would be. Patients, their families, and close friends should be able to recognize the most important signs and symptoms of depression and should know which healthcare professional to call should depression appear. However, no one except a professional is capable of accurately diagnosing depression. It is a good idea to try to develop an honest relationship with a healthcare professional you trust. Parents of a child who has cancer may find a parent support group helpful, as there is a great deal to learn from other parents who have been through a similar situation.

Treatments

Most important is that study after study has shown that depression in cancer patients can be successfully treated. It is important to understand that this problem probably can get better. Several different approaches to treatment can be taken, and several of these approaches can be effectively combined with one another

If the patient has a doctor or nurse capable of providing sustained emotional support, that can be helpful. On the other hand, it is important for patients to realize that doctors and nurses are usually extremely busy and that it may be necessary to find someone else to provide sustained emotional support. This other person may be a trained professional, such as a social worker, a psychiatric nurse, a psychologist, or a psychiatrist. The persons who provide support may also be family members or friends. A support group may be helpful. During periods of crisis, it is beneficial to have several people who can provide support. The family member or friend who is trying to provide such support should try to listen well and sympathetically.

Cognitive interventions

Cognitive interventions are also known as cognitive-behavioral treatment (CBT). CBT helps patients' view in a realistic way what is happening to them, where they are, and what they should or should not be doing. This type of intervention can be useful in helping patients give up negative perspectives and replace them with views that rely more upon the facts about what is going on. CBT may be practiced with a healthcare provider, or in a group with other patients and one or more providers.

Among the techniques CBT makes use of are:

  • Cognitive distraction: This is the phrase used for techniques that shift the mind-frame of the patient from negative things to more positive thoughts. Music is one of the basic tools of cognitive distraction. Patients should be encouraged to listen to the type of music they like best. Headphones may be helpful if brought to diagnostic and treatment sessions and occasions when waiting is necessary. Imagery is another technique important for cognitive distraction. Imagery can help the mind shift from negative thoughts and difficult situations to helpful images. Each patient should select those images that feel right and good. For one patient this may be swimming at the beach; for another, visiting special friends; for another, walking through the forest.
  • Psychoeducation: This CBT technique involves providing information to patients so patients can feel that what is going on is not entirely beyond their control. People often find it difficult to deal with the unknown, and psychoeducation attempts to remove some of what is unknown. Another important psychoeducation technique is having patients make lists of questions to ask their nurse or doctor.
  • Image rehearsal: This CBT technique involves working with a healthcare professional. The patient may use image rehearsal to rehearse some activity she or he finds to be stressful. For example, image rehearsal may be used if the patient finds MRI scans or radiation treatments to be stressful.

Other CBT techniques involve relaxation techniques and the conscious decision to participate in activities the patient likes doing.

Psychotherapy

Talking to a psychologist, social worker, psychiatric nurse, psychiatrist, or other health care professional can be helpful. In addition to the cancer and problems associated with therapy, this talk therapy can help the patient address unresolved matters that were already bothersome before cancer was diagnosed.

Group therapy

Studies have shown group therapy to be an effective approach for patients with cancer-related depression. Various approaches to group therapy may be taken. In all, however, it involves communication not only between patient and healthcare professional, but also among and between patients. Group therapy can also be helpful for loved ones of cancer patients.

Important to note is that studies have shown that cancer patients may tend to isolate themselves from friends and family. In other words, the amount of contact and communication between friends and family may be less than it had been before cancer was diagnosed. This is not a helpful trend. Research suggests that social support can have beneficial effects on a person's physical health. Group therapy can provide this type of social support to patients. In addition, group therapy may furnish a place where patients are able to learn about how to maintain contact with family and friends. It can also provide a way for patients to identify which family members and friends are not supportive.

Medication

A variety of antidepressant medications are available. Among those most frequently prescribed are psychostimulants, tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs). These medications help return the neurotransmitters to a normal, balanced function. There are at least three different psychostimulants, six different TCAs, three different SSRIs, and three different MAOIs that doctors may choose among. In addition, there are various other medications that have proven to be effective as treatment for depression. All of these drugs have been shown to work well in general; however, while one specific type of drug may be appropriate for one patient, another patient may require a completely different type of drug. Use of some of these drugs may be accompanied by side effects. Just as there are different antidepressant drugs, so are there different side effects that may appear. However, many patients have no side effects from antidepressant medications or, at most, exhibit only minor side effects. Other patients find that, although they had side effects from one drug, they experienced no side effects after they switched to another medication. Many patients find they are able to successfully combine medications and other treatment approaches, but honest communication with the physician is essential.

The suicidal patient

If a patient is suicidal it is extremely important to immediately contact a healthcare professional capable of dealing with such a crisis.

Resources

BOOKS

Spiegel, David, and Catherine Classen. Group Therapy for Cancer Patients: A Research-Based Handbook of Psychosocial Care. New York: Basic Books, 2000.

Waller, Alexander, and Nancy L. Caroline. Handbook of Palliative Care in Cancer 2nd ed. Boston: Butterworth Heine-mann, 2000.

Yarboro, Connie H., Margaret H. Frogge, and Michelle Goodman. Cancer Symptom Management. 2nd ed. Boston: Jones and Bartlett Publishers, 1999.

PERIODICALS

Lovejoy, Nancy C., Derek Tabor, Margherite Matteis, and Patricia Lillis. "Cancer-related Depression: Part INeurologic Alterations and Cognitive-Behavioral Therapy." Oncology Nursing Forum 27 (2000): 667-677.

Sheard, T., and P. Maguire. "The Effect of Psychological Interventions on Anxiety and Depression in Cancer Patients: Results of Two Meta-Analyses." British Journal of Cancer 80 (1999): 1770-1780.

ORGANIZATION

The National Cancer Institute.(800)4-CANCER. <http://www.nci.nih.gov>

The American Cancer Society. (800)ACS-2345. <http://www.cancer.org>

National Coalition for Cancer Survivorship. 1010 Wayne Avenue, 7th Floor, Silver Spring, MD 20910-5600. (301) 650-9127 and (877)NCCS-YES [(877)622-7937]. <http://www.cansearch.org>

Bob Kirsch

KEY TERMS

Cognitive-behavioral therapy

One of several effective ways of treating depression in cancer patients. CBT helps patients view what is happening to them in a realistic way. It may make use of music, imagery, and providing accurate information.

Depression screen

A questionnaire on how the patient is feeling used to help healthcare professionals diagnose depression.

Dysthymia

A milder form of depression.

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Kirsch, Bob. "Depression." Gale Encyclopedia of Cancer. 2002. Encyclopedia.com. 1 Jul. 2016 <http://www.encyclopedia.com>.

Kirsch, Bob. "Depression." Gale Encyclopedia of Cancer. 2002. Encyclopedia.com. (July 1, 2016). http://www.encyclopedia.com/doc/1G2-3405200146.html

Kirsch, Bob. "Depression." Gale Encyclopedia of Cancer. 2002. Retrieved July 01, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3405200146.html

Depression

DEPRESSION

Various forms of clinical depression are defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV). According to this classification scheme, five or more symptoms (see Table 1) must be present during the same two-week period, and they must represent a change from previous functioning, in order for a person to receive a diagnosis of major depressive disorder (MDD). At least one of these symptoms must be either depressed mood or loss of interest or pleasure (i.e., anhedonia). The symptoms must cause distress or impairment in social, occupational, or other important areas of functioning, and they must not be clearly and fully accounted for by the direct physiological effects of a substance or a general medical condition. The average episode length for major depression is approximately seven months.

In addition to major depressive disorder, dysthymic disorder is a less severe, but more chronic form of depression. Dysthymia is indicated by the presence of a depressed mood occurring on most days for a period of at least two years. Average episode length is approximately ten years, and the disorder often lasts for up to twenty or thirty years. To meet criteria for dysthymic disorder, a person must display, in addition to depressed mood, at least two of the following symptoms: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. The person must have these symptoms for more than two months to meet the criteria for diagnosis. As with major depression, these symptoms must cause distress or impairment in social, occupational, or other important areas of functioning, and must not be clearly and fully accounted for by the direct physiological effects of a substance or a general medical condition.

Individuals who do not meet criteria for a major depressive episode or dysthymic disorder may nonetheless display symptoms of depression. Estimates in the late 1990s indicated that approximately 10 percent of elderly primary-care patients display such subsyndromal depression. Research in the late 1990s and early 2000s suggests that subsyndromal depression among elderly persons is best viewed as a less intense form of major depressive disorder. That is, elderly persons with subsyndromal depression experience distress and impairment, but to a lesser degree than those who meet the full criteria for MDD. Two symptoms that may distinguish MDD from subsyndromal depression among elderly persons are suicidal thoughts and feelings of guilt or worthlessness.

A specific category of subsyndromal depression, bereavement, may be particularly likely to occur among elderly individuals due to higher mortality rates among this population. Bereavement is a normal reaction to the loss of a loved one. Bereaved individuals frequently display symptoms characteristic of MDD, although a diagnosis of MDD should not be made unless the symptoms persist for more than two months after the loss. The presence of any of the following symptoms may be indicative of MDD, as opposed to bereavement: guilt unrelated to actions taken at the time of death; thoughts of death other than a desire to have died with the deceased person; marked feelings of worthlessness; marked psychomotor retardation; marked functional impairment; and hallucinations that do not involve the deceased person.

One-year prevalence rates of depression among elderly persons vary depending on where they live and if they have a medical condition. For adults age sixty-five and older who live in the community and do not have a medical condition, the prevalence rate of MDD ranges from 1 to 6 percent. This prevalence rate is less than that for younger adults. However, when considering the prevalence rate for those that experience depressive symptoms but do not meet criteria for diagnosis, the rate for older adults increases to 20 to 30 percent. The one-year prevalence rate for individuals with dysthymia averages between 1 and 2 percent.

The one-year prevalence rates of MDD is higher for elder persons who live in nursing homes, compared to those who live in the community. For older adults who live in a nursing home, the prevalence rate for MDD ranges from 6 to 25 percent. When just considering depressive symptoms, the prevalence rate increases to between 16 and 30 percent. The one-year prevalence rate for older adults in nursing homes with dysthymia ranges from 16 to 30 percent, which is substantially higher than the rate for older adults in the community.

Depressive symptoms are common among individuals with medical conditions. One-year prevalence rates for elderly persons with medical conditions range from 6 to 44 percent. The rates can be higher among individuals with severe illnesses, such as cancer, or with more functional disabilities.

Depression can be usefully conceptualized within a diathesis-stress framework, where an individual will have certain factors that predispose him or her to depression. When these predisposing factors combine with a stressor, depression can result. There are various factors that can predispose someone to depression, some of which are biological. For example, having low or dysregulated levels of certain neurotransmitters, such as serotonin or norepinephrine, has been associated with depression. It has also been found that as people get older their levels of norepinephrine, as well as other neurochemicals, decrease. Another biological factor associated with depression is brain abnormalities similar to those seen with Alzheimer's disease or dementia. These brain abnormalities include enlargement of the ventricle areas and changes in white matter. Thus, changes in the neurochemistry, neurophysiology, and neuroanatomy can make one more vulnerable to depressive symptoms.

Other factors that can predispose an individual to depression are social and psychological in nature. Depressed individuals tend to have thought patterns that can distort reality and emphasize negative aspects of a situation. In addition, depressed individuals may view themselves, their future, and others in a negative light. These thought patterns produce behaviors that can predispose and exacerbate the individual's depression. For example, depressed individuals might seek reassurance or positive feedback from others. However, due to their negative views about themselves, they do not believe the feedback they receive and seek it again. This leads into a cycle of continuously seeking feedback, which eventually tires the other person and leads the depressed individual to eventually receive negative feedback. This pattern of thoughts and behaviors not only predisposes individuals to depression, but also helps maintain the depression.

Stressors and negative life events can also trigger and impact the severity of depression. Elderly persons may encounter various stressors in their lives, such as the death of loved ones, loss of physical agility and ability, loss of ability to work, caregiving for other individuals, physical disability, and medical illness. Diagnosing depression in the presence of physical disability and medical illness can be difficult. Numerous medical conditions, including cardiovascular, pulmonary, endocrine, infectious, malignant, metabolic, and neurological disorders, may lead elderly persons to present with symptoms of depression. For instance, hypothyroidism often presents as sadness, disinterest, fatigue, decreased appetite, and poor concentration. Certain medications may also produce side effects mimicking depressive symptoms. For example, cancer treatments may induce depression-like symptoms of fatigue, insomnia, and decreased appetite. Such disorders and medications should be ruled out before a mood-disorder diagnosis is made and treatment is implemented.

Older adults with medical illnesses and physical disabilities are more susceptible to depression, even when taking into account those symptoms that overlap. Approximately 60 to 85 percent of depressed older persons report a physical illness that preceded their depression. However, not all medically ill older adults suffer from depression. Other factors, such as social support and coping styles, can prevent older adults from having depression.

Treatment of depression

Three methods of treatment have been demonstrated to be effective among elderly persons: antidepressant medications, psychosocial interventions, and electroconvulsive therapy (ECT). Antidepressant medications can be divided into four classes. The first class, heterocyclic antidepressants (HCAs), includes medications such as nortriptyline (Pamelor, Aventyl), desipramine (Norpramin), bupropion (Wellbutrin), and trazedone (Desyrel). HCAs tend to produce unpleasant side effects such as dry mouth, constipation, and mild cognitive impairments. Moreover, they sometimes lead to orthostatic hypotension (low blood pressure that occurs when an individual stands upright) and cardiotoxic affects, which may be especially problematic among individuals with existing heart or blood pressure conditions. In general, bupropion and trazedone produce fewer adverse side effects than other HCAs.

Monoamine oxidase inhibitors (MAOIs) are the second class of antidepressant medications. Similar to HCAs, these medications often produce a number of unpleasant side effects. Moreover, they have potentially lethal interactions with other medications and foods, which may make treatment more difficult among persons who take other medications or who have trouble maintaining dietary restrictions. As a result, MAOIs are rarely used among elderly individuals. Examples of MAOIs include moclobemide (Aurorix), phenelzine (Nardil), and selegiline (Eldepryl).

The third class of antidepressants, serotonin reuptake inhibitors (SRIs), include medications such as paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft). SRIs typically produce fewer side effects than HCAs and MAOIs, are less reactive with other medicines, and are less lethal in overdose. Consequently, they may be preferable to the other classes. Evidence suggests that HCAs, SRIs, and MAOIs are comparably effective, producing improvement in 50 to 80 percent of depressed, elderly persons.

The fourth group of antidepressant medications is referred to as atypical because their chemical properties do not fit into any of the other classes. These medications have not yet been adequately studied among depressed, elderly persons. Thus, it is not currently known how effective they may be for this population. Examples of atypical antidepressants include nefazodone (Serzone) and venlafaxine (Effexor).

The duration of antidepressant treatment must be considered when treating depressed, elderly persons. Elderly persons typically respond to antidepressant medications more slowly than younger persons; twelve weeks of treatment may be required to achieve maximum response. Furthermore, treatment should be continued at the same dosage for a minimum of six months after remission to prevent relapse.

In addition to antidepressant medications, five psychosocial interventions have demonstrated efficacy for treating depressed, elderly persons: cognitive-behavioral therapy (CBT), brief psychodynamic therapy, interpersonal psychotherapy (IPT), reminiscence therapy, and psychoeducational approaches. A brief description of these therapies is presented in Table 2. CBT, IPT, and brief psychodynamic therapy all appear to be comparably effective to antidepressant medications, with improvement rates near 70 percent. Reminiscence therapy has been shown to be effective for mild and moderate cases of depression, but does not appear to be as effective as CBT for more severe cases of depression. Psychoeducational interventions are effective in reducing depressive symptoms among elderly persons with subsyndromal depression. Psychosocial interventions may be superior to antidepressants and electroconvulsive therapy at reducing the risk of future depression.

Electroconvulsive therapy (ECT) is a third form of treatment for depressed, elderly individuals. ECT involves passing electrical current through an individual's brain, and is typically used only in severe cases of depression that have not responded to other treatments. ECT appears to be as effective (and perhaps more effective) than antidepressant medications for the short-term treatment of MDD, particularly in severe and psychotic cases of depression. It typically produces a more rapid response than either antidepressants or psychosocial interventions. Nevertheless, the majority of individuals who receive ECT relapse into depression if they do not receive additional treatment. In addition, roughly one-third of elderly persons who receive ECT experience complications such as memory impairment, delirium, and arrythmias.

Although combinations of the three forms of treatment have not been researched thoroughly, a limited amount of data and common clinical practice indicate that antidepressant treatment combined with psychosocial interventions may be superior to either form of treatment administered alone. If the increased cost associated with a second form of treatment is feasible, and if combined treatment is not contraindicated for medical reasons, combined antidepressant and psychosocial interventions may provide the optimal treatment for depression among older adults.

Thomas E. Joiner, Jr. Jeremy W. Pettit Marisol Perez

See also Alzheimer's Disease; Antidepressants; Anxiety; Bereavement; Cognitive-Behavioral Therapy; Diagnostic and Statistical Manual of Mental Disorders-IV; Electroconvulsive Therapy; Neurotransmitters; Psychotherapy.

BIBLIOGRAPHY

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: APA, 1994.

Geislemann, B., and Bauer, M. "Subthreshold Depression in the Elderly: Qualitative or Quantitative Distinction?" Comprehensive Psychiatry 41, no. 2, supp. 1 (2000): 3238.

Lyness, J. M.; King, D. A.; Cox, C.; Yoediono, Z.; and Caine, E. D. "The Importance of Subsyndromal Depression in Older Primary Care Patients: Prevalence and Associated Functional Disability." Journal of the American Geriatrics Society 47, no. 6 (1999): 647652.

Niederehe, G., and Schneider, L. S. "Treatments for Depression and Anxiety in the Aged." In A Guide to Treatments that Work. Edited by Peter E. Nathan and Jack M. Gorman. New York: Oxford University Press, 1998. Pages 270287.

Wolfe, R.; Morrow, J.; and Fredrickson, B. L. "Mood Disorders in Older Adults." In The Practical Handbook of Clinical Gerontology. Edited by Laura L. Carstensen and Barry A. Edelstein. Thousand Oaks, Calif.: Sage Publications, 1996. Pages 274303.

Zarit, S. H., and Zarit, J. M. Mental Disorders in Older Adults: Fundamentals of Assessment and Treatment. New York: Guilford Press, 1998.

DESIGN

See Human factors

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Depression

Depression

Definition

When discussing depression as a symptom, a feeling of hopelessness is the most often described sensation. Depression is a common psychiatric disorder in the modern world and a growing cause of concern for health agencies worldwide due to the high social and economic costs involved. Symptoms of depression, like the disorder itself, vary in degree of severity, and contribute to mild to severe mood disturbances. Mood disturbances may range from a sudden transitory decrease in motivation and concentration to gloomy moods and irritation, or to severe, chronic prostration.

With treatment, more than 80% of people with depression respond favorably to medications, and the feeling of hopelessness subsides. With treatment, most people are able to resume their normal work and social activities.

Depression may occur at almost any stage of life, from childhood to middle or old age, as a result of a number of different factors that lead to chemical changes in the brain. Traumatic experiences, chronic stress, emotional loss, dysfunctional interpersonal relationships, social isolation, biological changes, aging, and inherited predisposition are common triggers for the symptoms of depression. Depression is classified according to the symptoms displayed and patterns of occurrence. Types of depression include major depressive disorder, bipolar depressive disorder, psychotic depressive disorder, postpartum depression, premenstrual dysphoric disorder, and seasonal disorder. Additional types of depression are included under the label of atypical depressive disorder. Many symptoms overlap among the types of depression, and not all people with depression experience all the symptoms associated with their particular type of the disorder.

Description

Symptoms of a depressive disorder include at least five of the following changes in the individual's previous characteristics: loss of motivation and inability to feel pleasure; deep chronic sadness or distress; changes in sleep patterns; lack of physical energy (apathy); feelings of hopelessness and worthlessness; difficulty with concentration; overeating or loss of appetite; withdrawal from interpersonal interactions or avoidance of others; death wishes, or belief in his/her own premature death. In children, the first signs of depression may be irritation and loss of concentration, apathy and distractibility during classes, and social withdrawal. Some adults initially complain of constant fatigue , even after long hours of sleep, digestive disorders, headaches, anxiety, recurrent memory lapses, and insomnia or excessive sleeping. An episode of major depression may be preceded by a period of dysthymia, a mild but persistent low mood state, usually accompanied by diminished sexual drive, decreased affective response, and loss of interest in normal social activities and hobbies.

Most individuals with depression have difficulty in dealing with the challenges of daily life, and even minor obstacles or difficulties may trigger exaggerated emotional responses. Frustrating situations are frequently met with feelings of despair, dejection, resentment, and worthlessness, with people easily desisting from their goals. People with depression may try to avoid social situations and interpersonal interactions. Some people with depression overeat, while others show a sharp loss of appetite (anorexia). In some individuals, medical treatments for some other existing illness may also cause depression as an adverse reaction. For instance, antihypertensive drugs, steroids, muscle relaxants, anticancer drugs, and opioids, as well as extensive surgery such as a coronary bypass, may lead to depression. Cancer and other degenerative diseases, chronic painful conditions, metabolic diseases or hormonal changes during adolescence, or after childbirth, menopause, or old age may be potential triggers for depression. When the first onset of depression occurs after the age of 60, there is a greater possibility that the causative factor is a cerebrovascular (blood vessels in the brain) degeneration.

Molecular genetics research has recently shown that mutations in a gene coding for a protein that transports serotonin (a neurotransmitter) to neurons may determine how an individual will cope with stressful situations. A two-decade study involving 847 people of both sexes has shown that those who inherited two copies of the long version of the gene 5-HTT have a 17% risk of suffering a major depressive episode due to exposure to four or more identified stressful situations in their lives, whereas those with one long and one short version of the gene had the risk increased to 33%. The study has also shown that individuals with two short copies of the gene have a 43% probability of a major depressive episode when exposed to four or more stressful life events. The shorter version of the gene 5-HTT does not directly causes depression, but offers less protection against the harmful effects of traumatic or stressful situations to the brain. Studies of population genetics have also shown that about 50% of the world's Caucasian population carry one short and one long version of 5-HTT genes.

Depressive episodes may be associated with additional psychiatric disorders. Neurotic depression is often triggered by one or more adverse life events or traumatic experiences that have historically caused anxiety in the life of the person experiencing depression. For example, loss of social or economical status, chronic failure in living up to the expectations of parents, teachers, or bosses, death of a close relation, work-related competitive pressures, and other stressful situations such as accidents, urban violence, wars, and catastrophic events may lead to a depressive episode. Conversely, anxiety disorders such as panic syndrome, phobias, generalized anxiety, and post-traumatic stress disorder may trigger a major depressive crisis. Psychotic depressive disorders are likely to be associated with other psychiatric diseases or caused by them. Eating disorders such as bulimia, anorexia nervosa, and binge-eating disorder are generally accompanied by depression or may be caused by an existing depressive state. Neurodegenerative diseases such as Alzheimer's, Huntington's, and Parkinson's diseases frequently have depression among their symptoms.

Dysthymia is a mild but chronic depressed state, characterized by melancholic moods, low motivation, poor affective responsiveness, and a tendency for self isolation. A dysthymic state lasting two years or longer is a risk factor for the onset of a major depressive episode. However, many dysthymic individuals experience a chronic low mood state throughout their daily lives. Dysthymia is a frequent occurrence in individuals involved in chronic dysfunctional marriages or unsatisfying work conditions. Such chronic stressful situations alter the brain's neurochemistry, thus the opportunity arises for symptoms of depression to develop.

Psychotic depression is a particularly serious illness and possesses biological and cognitive (thought) components. Psychotic depression involves disturbances in

brain neurochemistry as a consequence of either a congenital (from birth) condition or due to prolonged exposure to stress or abuse during early childhood. Prolonged exposure to severe stress or abuse in the first decade of life induces both neurochemical and structural permanent changes in the developing brain with a direct impact on emotional aspects of personality. Normal patterns of perception and reaction give way to flawed mechanisms in order for a person to cope with chronic fear, abuse, and danger. Perception becomes fear-oriented and conditioned to constantly scan the environment for danger, with the flight-or-fight impulse underlying the individual's reactions. Delusions, misinterpretation of interpersonal signals, and a pervading feeling of worthlessness may impair the individual's ability to deal with even minor frustrations or obstacles, precipitating deep and prolonged episodes of depression, often with a high risk of suicide. Hallucinations may also occur, such as hearing voices or experiencing visions, as part of depression with psychosis.

A major depressive disorder (MDD) or clinical depression may consist of a single episode of severe depression requiring treatment or constitute the initial sign of a more complex disorder such as bipolar disorder. MDD may last for several months or even years if untreated and is associated with a high risk of suicide. In bipolar disorder, manic (hyper-excited and busy) periods alternate with deep depressive episodes, and are characterized by abnormal euphoria (an exaggerated feeling of happiness and well-being) and reckless behavior, followed by deep distress and prostration, often requiring hospitalization.

Major episodes of depression may last for one or more years if not treated, leading to a deep physical and emotional prostration. The person with major depression often moves very slowly and reports a sensation of heaviness in the arms and legs, with simple walking requiring an overwhelming effort. Personal hygiene is neglected and the person often desires to stay secluded or in bed for days or weeks. Suicidal thoughts may frequently occupy the mind or become recurrent patterns of thinking. Painful or unsettling memories are often recalled, and contribute to feelings of helplessness.

Atypical depression causes a cyclic behavior, alternating periods of severe and mild depressive states, punctuated by mood swings, hypersensitivity, oversleeping, overeating, with or without intermittent panic attacks. This depressive disorder is more common in women, with the onset usually occurring during adolescence.

Premenstrual dysphoric disorder (PDD) is not premenstrual stress. It is a more severe mood disorder that can cause deep depression or episodes of heightened irritation and aggressiveness, starting one or two weeks before menstruation and usually persisting during the entire period. Premenstrual dysphoric disorder is associated with abnormal changes in levels of hormones that affect brain neurochemistry.

Seasonal affective disorder (SAD) is caused by disturbances in the circadian cycle, a mechanism that controls conversion of serotonin into melatonin in the evening and mid-afternoon, and the conversion of melatonin into serotonin during daytime. Serotonin is the neurotransmitter responsible for sensations of satiety and emotional stability, which is converted at nighttime into melatonin, the hormone that regulates sleep and other functions. Some people are especially susceptible to the decreased exposure to daylight during long winter months and become depressed and irritable. Overeating and oversleeping during the winter season are common signs of seasonal affective disorder, along with irritation and depressed moods. However, as the amount of light increases during the spring and summer seasons, the symptoms disappear.

Postpartum depression is a severe and long-lasting depressive state also associated with abnormal changes in hormone levels affecting brain neurochemistry. If untreated, postpartum depression may last for months or even years, and is highly disruptive to family and maternal-child relations.

Without treatment, the risk of suicide as a consequence of depression should not be underestimated. Suicide accounts for approximately 15% of deaths among people with significant depression, and half of all suicide attempts in the United States are associated with depression. Persistent and recurrent depressive episodes are important contributors to other diseases alike such as myocardial infarction, hypertension, and other cardiovascular disorders.

Resources

BOOKS

Klein, Donald F., MD. Understanding Depression: A Complete Guide to Its Diagnosis and Treatment. New York: Oxford Press, 1995.

Solomon, Andrew. The Noonday Demon: An Atlas of Depression. New York: Scribners, 2002.

PERIODICALS

Manji, H. K., W. C. Drevets, and D. S. Charney. "The Cellular Neurobiology of Depression." Nature Medicine (May 2001) 7: 541546.

Teicher, Martin H. "Wounds That Won't HealThe Neurobiology of Child Abuse." Scientific American (March 2002): 6875.

OTHER

National Institute of Mental Health. Depression. February 12, 2004 (March 31, 2004). <http://www.nimh.nih.gov/publicat/depression.cfm#ptdep1>.

ORGANIZATIONS

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (800) 615-NIMH (6464); Fax: (301) 443-4279. nimhinfo@nih.gov. <http://www.nimh.nih.gov>.

Sandra Galeotti

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Depression

Depression

An emotional state or mood characterized by one or more of these symptoms: sad mood, low energy, poor concentration, sleep or appetite changes, feelings of worthlessness or hopelessness, and thoughts of suicide.

Depression may signify a mood , a symptom, or a syndrome. As a mood, it refers to temporary feelings of sadness, despair, and discouragement. As a symptom, it refers to these feelings when they persist and are associated with such problems as decreased pleasure, hopelessness, guilt , and disrupted sleeping and eating patterns. The entire syndrome is also referred to collectively as a depression or depressive disorder. At any given time about 10 percent of all people suffer some of the symptoms of depression at an economic cost of more than $30 billion annually and costs in human suffering that cannot be estimated. The American Psychiatric Association estimates that about one in five Americans experiences an episode of depression at least once in his or her lifetime.

Depression can generally be traced to a combination of physical, psychological, and environmental factors. Depressive disorders involve a person's body, mood and thoughts.

Genetic inheritance makes some people more likely than others to suffer from depression. More than 60 percent of people who are treated for depression have family members who have been depressed at some time, and there is a 15 percent chance that immediate biological relatives of a depressed person will develop depression. Twin studies have also supported the existence of a genetic predisposition to depression, particularly bipolar depression. Researchers have found that depression is associated with changes in brain chemistry. The normal balance and functioning of two neurotransmitters in particularserotonin and norepinephrineappear to be disrupted in depressed persons, a finding that has led to the development of a variety of antidepressant drugs. Depression is also associated with an imbalance of cortisol, the main hormone secreted by the adrenal glands. Other physiological factors sometimes associated with depression include viral infections, low thyroid levels, and biological rhythms, including women's menstrual cycles depression is a prominent symptom of premenstrual syndrome (PMS) .

Life events, including developmental traumas, physical illness, problems in intimate relationships, and losses may trigger a depression. According to classic psychoanalytic theory, depression is the result of losing someone through death or abandonment and turning one's feelings of anger and resentment inward. For behaviorists, the link between such negative events as the death of a loved one, the end of a relationship, or the loss of a job is the removal of a source of reward. Cognitive theorists claim that depressed people develop destructive ways of thinking, which include blaming themselves when things go wrong, focusing on the negative side of events, and habitually jumping to excessively pessimistic conclusions.

Another psychological explanation of depression centers on the concept of learned helplessness , a phenomenon first observed in a laboratory setting when animals that had no control over their situations (such as changing their situation by pressing a lever) showed signs of depression. It has been found that lack of control over their own lives is also associated with depression in humans and may be especially relevant to depression in women, whose incidence of depression is twice that of men. Another factor that may be linked to depression in women is the tendency to dwell on negative events, a cognitive style that research has shown to be more common among women than among men, who are more likely to distract themselves from negative feelings by engaging in various forms of activity.

The Diagnostic and Statistical Manual (DSM) of Mental Disorder s, produced by the American Psychiatric Association, categorizes depression as an affective, or mood, disorder. The DSM criterion for clinical depression is the presence of at least five of the following symptoms almost every day for at least two weeks: depressed mood; loss of interest in activities; significant changes in appetite or weight; disturbed sleep patterns; agitated or slowed movements; fatigue; feelings of worthlessness or inappropriate guilt; trouble concentrating; and preoccupation with death or suicide . In a major depressive episode, these symptoms can persist for six months or longer without treatment. Usually, major depression first occurs in one's late twenties. In severe cases, people may be almost completely incapacitated, losing the ability to work, socialize, and even care for themselves. The depressive episode may eventually lift completely, or some symptoms may persist for as long as two years. More than half the people who suffer from major depression experience more than one episode. A serious complication of major depression is the threat of suicide. Some 60 percent of people who commit suicide are depressed, and 15 percent of those diagnosed with depression eventually commit suicide.

In dysthymia, a less severe form of depression, the symptoms are more prolonged but not disabling. Depressed mood is the major symptom. The depressed mood lasts at least two years for adults and one year for children with two or more of the other symptoms of clinical depression present. Bipolar disorder (manic depression) is characterized by the alternation of depression and mania , an overly elated, energetic state. Characteristic symptoms of mania include an inappropriately cheerful mood; inflated optimism and self-esteem ; grandiose notions; excessive energy with a decreased need for sleep; racing thoughts; increased talking; and irritability when confronted by obstacles or opposition. During manic episodes, people characteristically use poor judgment, make irrational decisions and may even endanger their own lives. In bipolar disorder, manic episodes lasting days, weeks, or even months, alternate with periods of depression. There may be a period of normalcy between the two or an immediate mood swing from one mode to the other.

Cyclothymic disorder, the bipolar equivalent of dysthymia, resembles bipolar disorder but consists of a less extreme pattern of mood swings. Another type of depression, seasonal affective disorder (SAD), follows an annual cycle triggered by seasonal variations in light and usually involves depression during the winter months; it is thought to be due to an excess of the sleep-inducing hormone melatonin. Sometimes depressions become severe enough and include features of psychosis . These cases which account for about 10 percent of all clinical depressionsare characterized by delusions or hallucinations and an especially high incidence of suicide.

Most people with clinical depression do not recognize that they have it and fail to seek treatment, blaming stress or physical ailments for their lack of well-being. Of those who do seek treatment either through psychotherapy , medication, or a combination of both, 80 percent improve, often within a matter of weeks. Psychotherapy alone is generally more effective for people with mild or moderate depression, while medication is advised for those whose depression is more severe or who have developed physical symptoms. Most persons receiving psychotherapy for their depression undergo short-term treatment lasting between 12 and 16 weeks. Treatment methods vary among g different schools of therapy and individual therapists. Cognitive behavior therapy focuses on helping patients identify and change negative thought patterns; interpersonal and family therapies emphasize strategies for improving one's relationships with others; and behavioral therapy involves monitoring one's actions and modifying them through a system of incentives and rewards.

Two types of medication traditionally used to treat depressiontricyclic antidepressants and monoamine oxidase (MAO) inhibitorsincrease the brain's supply of certain neurotransmitters, including norepinephrine and dopamine. Both medications are effective for many patients but can cause a variety of side effects, particularly MAO inhibitors. In recent years a new generation of antidepressants has been developed that affects levels of serotonin rather than norepinephrine. Among these selective serotonin reuptake inhibitors (SSRIs) is fluoxetine (Prozac), the most widely used antidepressant in the United States. It is effective in 60 to 80 percent of those who take it and has fewer side effects than previous types of antidepressants. Other SSRIs prescribed include sertraline (Zoloft) and paroxetine (Paxil). Lithium for many years has been used to treat manic episodes in persons with bipolar disorder. Other medications found to help control mood swings are: carbamazepine, which has gained wide acceptance in clinical practice, and valproate, approved by the Food and Drug Administration for first-line treatment of acute mania.

Whenever possible, persons suffering from depression should be urged to seek treatment through a private therapist, clinic, or hospital. There are special treatment centers for depression at medical centers throughout the country. A complete physical examination by a family physician or internist is the first step in getting appropriate treatment. Since certain medications and medical conditions, such as a viral infection, can cause depression-like symptoms, a physician can rule out these possibilities first.

See also Suicide/Suicidal behavior

Further Reading

Persons, Jacqueline B. Essential Components of Cognitive-Behavior Therapy for Depression. Washington, D.C.: American Psychological Association, 2000.

Sholevar, G. Pirooz. The Transmission of Depression in Families and Children: Assessment and Intervention. Northvale, N.J.: Aronson, 1994.

Volkan, Vamik D. Depressive states and their treatment. Northvale, N.J.: J. Aronson, 1994.

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Depression

DEPRESSION

Depression is a mood disorder, understood from the psychoanalytical viewpoint as resulting from an intrapsychic conflict that stems from the ego's difficulties in integrating aggressive drives that are experienced as too dangerous for the preservation of libidinally cathected objects. These aggressive drives turn against the subject via the superego, which becomes too strict and demanding. Depressive manifestations are frequent in other clinical entities where the conflicts are essentially intrapsychic, such as the psychoneuroses.

Karl Abraham (1912/1989) was one of the first psychoanalytical authors to concern himself with depressed patients and to describe the extent of the ambivalence of their drives. Narcissism is another characteristic of the depressive personality, which that Freud emphasized in "Mourning and Melancholia" (1916-17g [1915]). Subsequently, Abraham (1924/1927) described the pregenital underpinning of this ambivalence, given the importance of oral fixations in these patients.

Freud compared the psychological mechanisms of melancholia with those of mourning, which constitutes a depressive state in the normal person. The essential difference is the narcissism of the melancholic, whose intolerance of experiences of loss lead him to the oral incorporation of the lost object into the ego, where it is attacked by the superego. Conversely, the person in mourning finds himself faced with the painful difficulty of detaching the libido cathected onto the lost object so as to recathect it onto objects in the external world. However, the major problem raised by Freud's descriptions of the dynamics of melancholia is that he does not specify the variations in the psychological mechanisms corresponding to the different degrees of depressive states.

Melanie Klein (1940) developed the comparison with mourning in her description of the depressive position. For her, the capacity to work through one's mourning will depend on the possibility of resolving the reactivation of the conflict proper to the depressive position that the conflict causes, i.e., the feeling of losing good internal objects. Klein, like Freud, is imprecise when it comes to the different problematics of depression. However, clinical analysis shows a whole series of levels of severity in this problematic between the working through of the mourning process (or during the integration of the depressive position) and the peak of this process, which Klein described as "a melancholia in statu nascendi " (Palacio Espasa). These depressive forms of conflict can be defined by reference to the predominant form of the fantasies expressing the experiences of the loss of the object of libidinal cathexis, and by the quality of the types of anxiety experienced by the ego.

When fantasies of the catastrophic and irreparable destruction of the object predominate, given that the subject has very little confidence in his libidinal capacities, feelings of guilt become intolerable and feelings of sadness are massively denied. The ego can only resort to archaic mechanisms of defense: splitting, denial, projective identification, idealization, etc.the mechanisms proper to schizo-paranoid functioning or to the dynamics of extreme melancholia, with confusion between the ego and the object attacked (the "parapsychotic" depressive conflict proper to borderline or psychotic structures).

When fantasies of severe and barely reparable damage or death of the objects take the upper hand, the ego will be confronted with intense feelings of guilt and sadness. The significant repression of the aggressive drives towards the object (an aggressiveness that reinforces the severity of the superego) will make it possible for the negative affects to be partially denied. The ego will succeed in keeping the conflict interiorized but at the cost of diverse inhibitions in the functions of the ego. Thus, the symbolic possibilities of the individual are limited, but are not qualitatively affected. This very narrow form of repression is often insufficient, and the ego also has to resort to maniacal defenses or to defenses of a melancholic type, which then determine the clinical manifestations of mood disturbances.

When feelings of abandonment and rejection prevaili.e., when the experiences of loss are above all fantasies such as the loss of the object's lovedepressive conflict will take a "paraneurotic form." The feelings of sadness are often conscious, for guilt is less intense and can equally easily become conscious. The ego's greater confidence in its libidinal capacities gives these subjects a profusion of fantasies of reparation that will counteract the damage done to the object, damage that is fantasized as resulting from their own aggressiveness. These fantasies underlie many of the neurotic mechanisms of defense, especially those of an obsessional kind, for example retroactive cancelling, reaction formation, etc. Under their influence, repression authorizes a greater possibility of symbolic expression, which distinguishes neurotic repression from the massive repression of the depressive type. Such a libidinal predominance changes the nature of what is repressed, for the counter-cathexis does not operate on aggressiveness alone, but also on the libidinal fantasies of an incestuous nature. This contributes to the sexual differentiation of parental objects, bringing into operation the conflict occasioned by triangulation and the Oedipus complex.

Francisco Palacio Espasa

See also: Abandonment; Acute psychoses; Adolescent crisis; Anaclisis/anaclitic; Anxiety; Dead mother complex; Depressive position; Essential depression; Guilt, unconscious sense of; Identification; Internal object; Lost object; Manic defenses; Mania; Melancholia; Mourning; "Mourning and Melancholia"; Psychoanalytical nosography; Self-punishment; Suicide; Superego; Transference depression.

Bibliography

Abraham, Karl. (1927). The process of introjection in melancholia: two stages of the oral phase of the libido. In Douglas Bryan and Alix Strachey (Trans.). Selected papers of Karl Abraham, M.D. (pp. 442-452). London: Hogarth. (Original work published 1924)

. (1927). Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. In Douglas Bryan and Alix Strachey (Trans.), Selected papers of Karl Abraham, M.D. (pp. 137-156). London: Hogarth and the Institute of Psycho-analysis. (Original work published 1911)

Freud, Sigmund. (1916-17g [1915]). Mourning and melancholia. SE, 14: 237-258.

Klein, Melanie. (1940). Mourning and its relation to manic-depressive states. International Journal of Psycho-Analysis, 21, 125-153.

Palacio Espasa, Francisco. (1993). La Pratique psychothérapique avec l'enfant. Paris: Bayard.

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Depression

Depression

Depression is one of the most common mood disorders. Everyone experiences depressed moods from time to time. More commonly referred to as "having the blues" or "being down in the dumps," the sad or depressed mood usually lasts for only a short period. When the feeling persists for weeks without apparent reason, however, it may be a sign of major depression, a psychiatric disorder.

The symptoms of major depression include a sad or depressed mood or a marked lack of interest and pleasure in almost all activities. This feeling persists for most of the day, nearly every day, for at least two weeks. In addition, many or all of the following symptoms occur: (1) loss of appetite; (2) fatigue (tiredness); (3) difficulty sleeping; (4) feelings of guilt or worthlessness; (5) lack of concentration; (6) thoughts of death, often including suicidal thoughts or plans, or even a suicide attempt.

People with major depression are also very likely to experience headaches, stomachaches, or pains or aches almost anywhere in their bodies. Major depression affects twice as many women during their lifetimes as it does men.

Words to Know

Bipolar disorder: Formerly manic-depressive illness, a condition in which a patient exhibits both an excited state called mania and a depressed state.

Electroconvulsive therapy: A form of treatment for depression in which an electric current is passed through the brain to produce convulsions.

Lithium: Natural mineral salt used as a medication to treat bipolar disorder.

Mania: Condition in which a person experiences exaggerated levels of elation.

Neurotransmitter: Chemical that transmits electrical impulses from one cell in the nervous system to another.

Causes of depression

No one knows the fundamental cause of major depression. Scientists believe this disorder might be caused by a low level of certain chemicals in the body known as neurotransmitters (pronounced nur-o-trans-MI-ter). These are chemicals that transmit information (electrical impulses) from one cell in the nervous system to another.

Thus, depression may be more a biological than a psychological disorder. This conclusion is supported by the way depression often runs in families: up to 25 percent of those with depression have a relative with a mood disorder of some kind. Furthermore, if one member of a pair of identical twins has major depression, the odds are about two in five that the other one will, too.

No one is quite sure why major depression affects more women than men. It could be that women, because of their monthly hormonal changes, are more biologically vulnerable. Another explanation might be that our society puts added pressures and limitations on women's lives, which could lead to feelings of helplessness and depression. One more explanation could be that women and men experience the same rate of depression, but that women are more open about their feelings and are more inclined to seek professional help if they have a problem.

Bipolar disorder

Another mood disorder is bipolar disorder (formerly called manicdepressive disorder). At first, bipolar disorder often seems to be depression. A person suffering from either of these disorders experiences periods of depression. However, in bipolar disorder, a person goes from periods of depression into periods of exaggerated elation (happiness), called mania. Manic people have excessive energy. They may feel exuberant, creative, and ready to take on the world. They often feel that they need little sleep and may even get only three or four hours of sleep during the manic episode. Other symptoms of mania include irritability, rapid and loud speech, and an inflated self-confidence.

Treatment

Medications known as antidepressants are considered standard therapy for depression. These medications raise the level of certain neurotransmitters in the body. Psychotherapy, used either alone or along with medication, is also an effective treatment for depression. Psychotherapy allows the psychiatrist to help a depressed person change his or her distorted views and beliefs about themselves and the world.

Both medication and psychotherapy typically take several weeks or months to become fully effective, and neither can help everyone. For those who are not helped, or whose symptoms are very severe, an alternative is electroconvulsive therapy (ECT; sometimes informally called shock therapy). In this therapy, electrodes are applied to the head (or to one side of the head) and the patient receives an electric shock strong enough to cause muscle spasms and convulsions.

The main drawback to ECT is temporary memory loss. Patients usually recover most of their missing memories within six to nine months. However, the few days immediately before the therapy are permanently lost. Since ECT can be a life-saving treatment for severely depressed people, it is appropriate when nothing else can provide help fast enough.

Bipolar disorder is most often treated with lithium, a natural mineral salt. While there has been a great deal of success in treating bipolar disorder patients with lithium and returning them to a normal life, researchers are not exactly sure how it works. It is a nonaddictive medication, but its dosage must be carefully monitored. Possible side effects of lithium therapy are stomachache, nausea, vomiting, diarrhea, hand tremors, thirst, fatigue, and muscle weakness.

Lithium therapy now allows many people with bipolar disorder to participate in ordinary everyday life. Seventy to 80 percent of bipolar patients respond well to lithium treatment without any serious side effects.

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Depression

DEPRESSION

Depression is sometimes referred to as the common cold of mental illness. It is a debilitating disease with significant societal costs. It is, however, one of the most clearly defined and treatable of mental illnesses. Technically, the term "depression" is used to cover a variety of symptomatic conditions, all characterized by negative mood and a loss of pleasure. Together these conditions comprise a spectrum ranging from major depression to dysthymia to adjustment reactions to normal grief and sadness. At one extreme of this continuum lies major depressive disorder, a syndrome characterized by severe episodes of depressed mood accompanied by loss of sleep, appetite, concentration, energy, and hope. The depressed mood must persist for greater than two weeks in order to warrant this diagnosis. At the other end of the continuum lies the diagnosis of dysthymia, which is characterized by a lower level of mood disturbance that persists chronically; that is, involving more days than not for a period of two years or greater. Many patients complain of depressed mood but do not fit neatly into either of these two categories. These patients' symptoms are frequently best accounted for as a reaction to an acute life stressor. These reactions are typically nonpathological and resolve with time, but they may constitute an adjustment reaction if normal functioning is sufficiently disturbed.

Depression is both common and costly. It has a lifetime prevalence of 5 to 10 percent of women and 2 to 5 percent of men. It is an expensive disorder in both direct and indirect terms, as depression causes a higher degree of functional disability than many medical illnesses including diabetes, chronic lung disease, and arthritis. Additional costs to society result from the effect of untreated depression on the treatment of medical illnesses, where it contributes to longer hospital stays and morbidity. This has been particularly well demonstrated in the treatment of myocardial infarction (heart attack), where the presence of major depression has consistently been found to increase mortality.

Depressive illness is thought to result from a combination of biological and psychological factors. The biological component is strongly suggested by the high genetic concordance of depressive disorders. In the twenty-first century, there are various competing theories about the nature of this genetic/biological contribution, but the available data do not yet indicate the specific nature of the illness. The psychological component is similarly suggested by the correlation of onset of major depression with negative life events and with the increased risk of depression in individuals who experienced abuse in childhood. A variety of psychological theories exist and are linked to models of psychotherapeutic treatment. Interpersonal psychotherapists, for example, emphasize the role of grieving due to the loss of an important relationship or a transition in social roles (e.g., transition from working to retirement, marriage to divorce). Cognitive therapists emphasize a mind-set of construing life events in a way that leads to depression. Alternately, psychodynamic therapists search for the ways that unconscious coping processes and repetitive relational patterns result in negative effects. A commonly postulated mechanism would include the turning of anger in on the self. For example, a depressed woman may feel critical of herself rather than direct her anger toward an abusive spouse.

Treatment of depression parallels theories of etiology in that both biological and psychological treatments exist and have been efficacious. A number of different antidepressant medications have been developed, including monoamine oxidase (MAO) inhibitors, tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRI). These medicines have demonstrated efficacy in both the treatment of acute depressive episodes and in the prevention of relapses. A variety of psychological therapies are also employed in the treatment of depression. Interpersonal psychotherapy and cognitive behavioral psychotherapy are psychotherapeutic models for which depression-specific therapeutic techniques have been developed. These tend to be delivered in the form of brief semi-structured treatments, lasting less than a year in duration. One advantage of these approaches is that they have been well tested in research settings and have an established record of effectiveness in appropriately selected patients. There is also some clinical consensus that long-term psychodynamic (emphasizing unconscious mental processes) therapies are also helpful, especially when the mood disorder exists in the context of a long-standing personality disorder.

James Powers

Stuart J. Eisendrath

(see also: Mental Health )

Bibliography

Eisendrath, S. J., and Lichtmacher, J. E. (1999). "Psychiatric Disorders." In Current Medical Diagnosis and Treatment 1999, eds. L. M. Tierney, S. J. Mcphee, and M. A. Papadakis. Stamford, CT: Appleton & Lange.

Gabbard, G. O. (1994). Psychodynamic Psychiatry in Clinical Practice: The DSM-IV Edition. Washington, DC: American Psychiatric Press.

Panzarino, P. J. (1998). "The Costs of Depression: Direct and Indirect: Treatment versus Nontreatment." Journal of Clinical Psychiatry 59(20):1114.

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depression (in psychiatry)

depression, in psychiatry, a symptom of mood disorder characterized by intense feelings of loss, sadness, hopelessness, failure, and rejection. The two major types of mood disorder are unipolar disorder, also called major depression, and bipolar disorder, whose sufferers are termed manic-depressive (see bipolar disorder). Other types of depression are recognized, with characteristics similar to the major mood disorders, but not as severe: they are adjustment disorder with depression, dysthymic disorder, and cyclothymic disorder.

Close to 20% of Americans are likely to suffer major depression at some time, and women tend to be more susceptible to the disorder than men. Major depression is likely to interfere significantly with everyday activity, with symptoms including insomnia, irritability, weight loss, and a lack of interest in outside events. The disorder may last several months or longer—and may recur—but it is generally reversible in the short run.

Bipolar disorder is much rarer, affecting only about 1% of the U.S. population; women and men tend to be equally susceptible. Its sufferers alternate between states of depression—similar to that which is experienced in unipolar disorder—and mania, which is characterized by intense euphoria and frenetic activity. Bipolar disorders are often interspersed with periods of relatively normal behavior, which may last for long periods of time between episodes of depression or mania. Manic-depressives have an extremely high rate of suicide, and episodes of the disorder tend to recur.

Medical evidence suggests that depressive states may be connected to deficiencies in the neurotransmitters norepinephrine and serotonin. Drug therapy includes various antidepressants that act on the flow of neurotransmitters and lithium for bipolar disorder (antidepressants can cause mania when used to treat depression in bipolar patients). There also has been success with electroconvulsive therapy (ECT) for major depression.

In recent years, theorists have argued that many depressed individuals depend upon others for their self-esteem, and that the loss of one of these emotional supports often precipitates a depressive reaction. A number of psychologists contend instead that depression is a result of learned helplessness, which occurs when a person determines through experience that his actions are useless in making positive changes. Other theorists have shown that genetic factors play a role in depression.

See L. Wolpert, Malignant Madness (2000).

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depression

depression, clinical depression Mental states characterized by feelings of sadness, hopelessness, and loss of interest, experienced by most individuals. They are deemed clinical (that is a mental illness) if they are persistent, severe, and out of proportion to any identifiable precipitant. The term depression entered psychiatric classification primarily as a symptom of melancholia (the predecessor to depression) and has only featured as a diagnostic label since the end of the nineteenth century (initially in the term manic depression).

The precise differentiation of types of depression varies. In the post-war period it has been common to distinguish reactive and endogenous depression. With reactive depression—a neurosis—there is an identifiable precipitant, but the response is exaggerated. With endogenous depression—a psychosis—there is not; instead the illness appears to arise from within. However, the DSM-III, under the heading of ‘Affective Disorders’, distinguishes bi-polar (manic depression) and unipolar disorders (depression).

The various types of depression are now the most frequently diagnosed mental illnesses, and are more common in women than men (with a usual ratio of two to one). There are undoubtedly biochemical changes associated with depressive states (though work on the biochemistry of depression has not been very successful) and the most widely used treatments are physical—drugs or ECT (electro-convulsive therapy). However, the case for the importance of social factors in the aetiology of depression is strong. George Brown and Tirril Harris's study of the Social Origins of Depression (1978) demonstrated very clearly that adverse life-events and other stress-inducing occurrences, when combined with situationally generated vulnerability, increased the chances of clinical depression (both reactive and endogenous).

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depression

de·pres·sion / diˈpreshən/ • n. 1. severe despondency and dejection, typically felt over a period of time and accompanied by feelings of hopelessness and inadequacy. ∎  Med. a condition of mental disturbance characterized by such feelings to a greater degree than seems warranted by the external circumstances, typically with lack of energy and difficulty in maintaining concentration or interest in life: clinical depression. ∎  a long and severe recession in an economy or market: the depression in the housing market. ∎  (the Depression or the Great Depression) the financial and industrial slump of 1929 and subsequent years. 2. the lowering or reducing of something: the depression of prices. ∎  the action of pressing down on something: depression of the plunger delivers two units of insulin. ∎  a sunken place or hollow on a surface: the original shallow depressions were slowly converted to creeks. ∎  Astron. & Geog. the angular distance of an object below the horizon or a horizontal plane. ∎  Meteorol. a region of lower atmospheric pressure, esp. a cyclonic weather system.

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depression

depression (di-presh-ŏn) n.
1. a mental state characterized by excessive sadness.

2. a mental illness characterized by the pervasive and persistent presence of certain symptoms on most days for at least two weeks. These symptoms include low mood, loss or impairment of motivation, energy, interest, and enjoyment, impaired memory and concentration, loss of appetite and libido, insomnia, and early morning wakening. Treatment for depression is usually with antidepressant drugs, cognitive behavioural therapy, and/or psychotherapy. See also postnatal (depression).
depressive adj.www.rcpsych.ac.uk/mentalhealthinformation/mentalhealthproblems/depression.aspx "Explanation of depression, including downloadable leaflets, from the Royal College of Psychiatrists"

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Depression

DEPRESSION

The term depression has been used to refer both to an emotional state and a group of psychiatric disorders. As an emotional state, it is also known by various comparable terms: dejection, despair, sadness, despondency, lowering of spirits. Cognitions (perceptions and judgments) of a negative nature often accompany depressed mood.

Most people experience brief periods of depressed or despondent mood, often in response to a disappointing life event. Each individual utilizes different Coping skills and relies on available social supports to deal with such episodes, which generally pass within hours to days.

When a dysphoric mood becomes more severe, is persistent, and impairs functioning, a major depression as a clinical syndrome has developed. Concurrent clinical features include a loss of interest or pleasure in usual activities, a sense of hopelessness, poor or alternatively increased sleep, loss of appetite or overeating with resultant changes in weight, fatigue, anxiety, restlessness, obsessive thinking, difficulty concentrating, irritability, feelings of worthlessness, recurring thoughts of death, and suicidal ideation or an actual attempt to end one's life. Suicidal disturbances are of serious concern; approximately 66 percent of depressed patients contemplate suicide, and it is estimated that 10 to 15 percent succeed. In some cases, psychotic features such as hallucinations and delusions may develop.

Depression is one of the most common psychiatric disorders seen in adults. The lifetime prevalence of major depressive disorder (using DSM-III-R criteria) in the United States is estimated to be 12.7 percent in men and 21.3 percent in women. Some individuals suffer from chronically depressed mood of a less intense nature than that experienced in a major depressive episode; this is referred to as dysthymia. A depressive syndrome may occur as part of manic-depressive illness, and depression as a symptom (i.e., a depressed mood) can be found in many other psychiatric disorders.

Depression should be distinguished from the normal despair of bereavement and from the various medical disorders (e.g., Parkinson's disease) and chemical agents (e.g., alcohol or drugs for heart conditions) that can produce symptoms of depressed mood. The cause of depression is unknown. Biological factors (e.g., dysregulation of neurotransmitter systems), genetic factors, and psychosocial factors (e.g., life events, learned behaviors, and cognitions) have been proposed, and it is likely that all interact to varying extents. Depression is a treatable (but not really curable) illness in the vast majority of people. Treatment consists of a number of modalities, depending on the type and severity of the depression. Psychotherapy, anti-depressant medications, and electroconvulsive therapy are the main interventions used.

(See also: Causes of Substance Abuse ; Complications: Mental Disorders )

BIBLIOGRAPHY

Gruenberg, A. M., & Goldstein, R. D. (1997). Depressive disorders. In A. Tasman, G. Kay, & J. A. Lieberman (Eds.), Psychiatry, 1st ed. Philadelphia, PA:W. B. Saunders Company.

Keller, M.B. (Ed.) (1988). Unipolar Depression. In A. J. Frances & R. E. Hales (Eds.), American Psychiatric Press review of psychiatry (Vol. 7). Washington DC: American Psychiatric Press.

Kessler, R. C., et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-19.

Myroslava Romach

Karen Parker

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depression

depression
1. Enclosed area of low pressure revealed by the pattern of pressure distribution. Depressions are also described as cyclones, or cyclonic systems, and have a characteristic pattern of wind circulation (anticlockwise around low pressure areas in the northern hemisphere). Mid-latitude depressions are associated with the convergence of polar and tropical air masses along a frontal zone: this commonly becomes deformed, and each air mass in turn advances over parts near (especially south of) the depression path, bringing first a warm and then a cold front.

2. The downward convexing of a crest line in a non-cylindroidal fold.

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AILSA ALLABY and MICHAEL ALLABY. "depression." A Dictionary of Earth Sciences. 1999. Encyclopedia.com. 1 Jul. 2016 <http://www.encyclopedia.com>.

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depression

depression An enclosed area of low pressure revealed by the pattern of pressure distribution. Depressions are also described as cyclones or cyclonic systems, and have a characteristic pattern of wind circulation (anticlockwise around low-pressure areas in the northern hemisphere). Mid-latitude depressions are associated with the convergence of polar and tropical air masses along a frontal zone: this commonly becomes deformed, and each air mass in turn advances over parts near (especially south of) the depression path, bringing first a warm and then a cold front.

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Depression

Depression

More Than Ordinary Sadness

Who Gets Depressed?

How Do People Know If They Are Depressed?

What Causes Depression?

Types of Depressive Illnesses

How Is Depression Treated?

Experiencing Depression

Resources

Organizations

Depression (de-PRESH-un) is a condition that causes people to feel long-lasting sadness and to lose interest in activities that normally give them pleasure. People with depression have continuing negative and pessimistic thoughts. They may experience changes in eating and sleeping patterns and in their ability to concentrate and make decisions.

KEYWORDS

for searching the Internet and other reference sources

Bipolar disorder

Dysthymia

Major depression

Mood disorders

Seasonal affective disorder

More Than Ordinary Sadness

Everyone feels sad occasionally, especially after a loss or a setback. Feeling down for short periods is perfectly normal. However, when sadness lasts several weeks and starts to interfere with normal activities, such as studying, relationships with friends and family, attendance at school, or activities that are normally fun, then it is more than an ordinary variation in mood. It is depression.

Depression is sometimes called an invisible disease, because it does not produce a rash or a fever or any other easily recognizable sign of a problem. In addition, many people are afraid or embarrassed to talk about how unhappy or hopeless they feel, mistakenly believing the feelings are a sign of weakness or a character flaw on their part. Sometimes those close to a person experiencing depression add to this mistaken belief by encouraging the person to simply cheer up. Because it often goes unrecognized, depression often goes untreated, but it is just as important to treat depression as it is to treat illnesses like diabetes or asthma. Depression should be treated by a mental health professional. The good news is that 80 to 90 percent of people with depression can be helped by treatment, often within a few weeks. Left untreated, however, depression can get worse and last longer. This needlessly reduces a persons full participation in life. In severe cases, it can lead to suicide.

Who Gets Depressed?

Depression is a common illness that appears in several different forms. Up to 1 out of every 12 teenagers suffers from depression. In addition, about 1 out of every 10 adults experiences a period of depression in any given year. About one-fourth of all women and one-eighth of all men will experience at least one episode of depression during their lifetime.

Depression can be found in children, in elderly people, and in people of all ages in between. It affects people of all races, cultures, professions, and income levels. Women, however, experience depression about twice as often as men. The economic costs of depression in the United States, including lost wages, lost productivity, and treatment, are between $30 billion and $44 billion every year.

How Do People Know If They Are Depressed?

Depression differs from ordinary sadness or grief. With depression there is:

  • a persistent feeling of sadness or emptiness that occurs daily and lasts longer than 2 weeks
  • unhappiness or a feeling of worthlessness or guilt that interferes with normal activities
  • loss of pleasure in activities that once were enjoyable, such as taking part in hobbies, listening to music, or going out with friends.

Not everyone experiences depression in the same way, but in addition to the symptoms listed above, other common changes that can occur include:

  • eating too much or too little
  • sleeping too much or too little; difficulty getting up or going to sleep
  • unexplained periods or restlessness, irritability, or crying
  • fatigue and decreased energy, even when getting enough sleep
  • difficulty concentrating or remembering things
  • difficulty making decisions
  • increased interest in death
  • thoughts of suicide

In his autobiographical book Darkness Visible, William Styron explores the possible sources of his debilitating depression, his recovery, and the history of this illness which has affected many other artists and writers. ©Liaison/Newsmakers/OnlineUSA

Preteens and teenagers experience many of these symptoms, but there are additional symptoms of depression that are common in young people. These include:

  • ongoing physical problems, such as headaches, digestive problems, or persistent aches and pains that have no obvious physical explanation and do not respond to medical treatment
  • increased absences from school or worsening school performance
  • talking about or acting on the desire to run away from home
  • unexplained outbursts of shouting, complaining, or crying
  • increased irritability, anger, or hostility
  • extreme sensitivity to failure or rejection
  • being bored
  • lack of interest in friends and a desire to isolate oneself
  • increased difficulties in relationships with family, friends, or teachers
  • alcohol or substance abuse
  • reckless behavior
  • abnormal fear of death

Because depression can involve physical symptoms, people with depression often consult their physician. This is very helpful since symptoms of depression can be symptoms of medical conditions as well. A medical check-up can determine if there is some medical reason for their symptoms, such as another disease or a side effect of medication. If these reasons are ruled out, a likely cause is depression. The physician may ask about feelings of sadness, hopelessness, or discouragement, loss of pleasure, and sleeping and eating problems to confirm a diagnosis of depression. The physicians then can discuss treatment options with the person, which may include a referral to a mental health professional for psychotherapy and, in some cases, medication.

What Causes Depression?

Experts are not exactly sure what causes depression. Depression is complex, but it appears to have mental, physical, genetic, and environmental components. These parts come together in different ways, making it difficult to pinpoint the exact cause of depression or predict who will become depressed and under what circumstances. One thing that is certain is that depression is not a weakness or a character flaw. It is not laziness or intentional bad behavior. People with depression cannot simply pull themselves together and drive out their sad and empty feelings, no matter how much the people around them encourage them to snap out of it.

Mental components

Depression affects a persons thoughts, but it also seems that a persons thoughts can affect depression. Why this happens is not clear. Some experts believe that depression comes from anger that is not expressed, but is directed inward at oneself instead. Others believe that negative thoughts feed depression, and that people who think negative things about themselves, the world around them, and the future encourage and deepen the depression. Feelings of being helpless and of having no choices, even if in reality choices exist, also can be mental components of depression. People who have low self-esteem and perfectionists who set unrealistic goals for themselves also are prone to depression.

Physical components

Researchers have found a link between depression and an imbalance of certain chemicals in the brain, called neurotransmitters*. Brain imaging techniques show that areas of the brain responsible for moods, thinking, sleep, appetite, and behavior function differently in some people with depression. In addition to differences in brain chemistry, some medical illnesses, such as stroke*, heart attack, cancer, or diseases that cause long-lasting pain, can sometimes trigger depression. In women, hormonal changes that occur just after the birth of a child cause some new mothers to experience postpartum (post-PAHRtum) depression, also called the baby blues. For most women, this is a mild, short-lived problem that goes away on its own after a week or so. In a few cases, though, the problem is more severe and long-lasting, and treatment is required.

* neurotransmitter
(NUR-o-transmit-er) is a chemical produced in and released by a nerve cell that helps transmit a nerve im-pulse or message to another cell.
* stroke
is a disorder in which an area of the brain is damaged due to sudden interruption of its blood supply. This is often caused by a blood clot blocking a blood vessel supplying the brain.

Genetic components

It appears that genetic (inherited) factors also cause vulnerability to some kinds of depression. This is demonstrated by the way that depression tends to run in families, and by twin research. Studies of twins have found that identical twins (twins who have the same genes*) are twice as likely to both experience major depression as are fraternal twins (twins who do not share all the same genes). Although a person with a parent, brother, or sister who has a depressive illness is more likely to become depressed than someone with no such family history, many people who have relatives with depression are not themselves depressed. For other people, depression seems to come out of nowhere, with no family history of the condition. This indicates that while genetic factors certainly contribute to depression, other factors play a significant role in whether the depression actually develops.

* gene
is a chemical found in the chromosomes in the bodys cells that passes on information, such as eye color, height, or other characteristics, from parent to child.

Environmental components

The death of a loved one, a failure at school or on the job, the end of a romantic relationship, or many other kinds of losses can trigger an episode of depression in some people. Depression is different from the normal mourning process that follows a loss. A person in mourning goes through distinct stages of psychological reaction to the loss, ending with the ability to accept the loss and resume normal functioning. With depression, the sadness continues over a long time with no progress being made toward acceptance of the change. There is no way to predict which environmental stresses will trigger depression in specific individuals.

Types of Depressive Illnesses

Depression can take a variety of forms. It may be mild, moderate, or severe. It may be mixed with periods of normal feelings or periods of abnormally heightened energy called manic (MAN-ik) periods, or depression may be continuous but low level. Some depressions occur seasonally. Although feelings of sadness, unworthiness, discouragement, and loss of interest in normally pleasant activities are common to all forms of depression, different depressive illnesses have different patterns of symptoms and are treated somewhat differently.

Major depression

Major depression is a combination of the symptoms listed above that is serious and long-lasting enough to interfere with daily life. It is also called unipolar depression. Major depression is the leading cause of disability in the United States and worldwide, because it can become severe enough to leave people unable to work, concentrate, learn, or care for themselves or their family. If left untreated, major depression can last for months or longer. Some people have only one period of major depression in their lives. For many others, however, episodes of major depression come and go for years.

Dysthymia

Dysthymia (dis-THI-mee-a) is the name given to a long-lasting depressed mood that is less severe than major depression, but which continues at a low level for a long time. People with dysthymia feel sad and show at least two other symptoms of depression for at least 2 years. Dysthymia often goes undiagnosed, because it is not disabling. However, it does leave people feeling sad and empty and keeps them from enjoying life and functioning at their best. Many people who have dysthymia also have episodes of major depression during their lives.

Bipolar disorder

Bipolar (by-POLE-are) disorder used to be called manic-depressive illness. It has two faces. One face is major depression. The other is mania (MAY-nee-a), an unnaturally high mood in which a person may be overactive, overtalkative, or filled with tremendous energy. The severe lows of depression alternate with the extreme highs of the manic phase. Symptoms of mania include:

  • great energy; ability to go with little sleep for days without feeling tired
  • severe mood changes from extreme happiness or silliness to irritability or anger
  • overinflated self-confidence; unrealistic belief in ones own abilities
  • increased activity, restlessness, or distractibility; inability to stick to tasks
  • racing, muddled thoughts that cannot be turned off
  • impaired judgment of risk and increased reckless behavior.

For most people, the mood swings between depression and mania occur over a long period of time, sometimes years. If bipolar disorder is left untreated, though, the intervals between mood shifts tend to become shorter and shorter. In children, the cycle is usually quite short, sometimes occurring several times in a day.

Bipolar disorder is not as common as major depression. About 1 out of every 100 people has bipolar disorder, and unlike major depression, it occurs equally often in men and women. However, bipolar disorder appears to be more likely to run in families than major depression.

Adjustment disorder with depressed mood

It is not uncommon for people of all ages to respond to certain life stressors with emotional and behavioral symptoms. For example, someone may become depressed after losing a job or when a loved one has died. Another person may feel worried, anxious, or vulnerable after an injury or illness. A child or teen may have trouble concentrating in school or show some disruptive behavior in the months following his or her parents divorce.

When symptoms are too mild to be diagnosed as another mental health condition and occur as a reaction to a specific known life situation, the condition is called an adjustment disorder. Because people may react to difficult life circumstances with a variety of different types of emotions and behaviors, there are many types of adjustment disorders.

When the main symptoms of an adjustment disorder are depressed mood and related changes in feelings and behavior, such as feeling hopeless and crying a lot, the condition is called adjustment disorder with depressed mood.

With adjustment disorder, the symptoms are temporary and disappear within 6 months after the source of stress has been removed.

Seasonal affective disorder (SAD)

SAD is a form of depression that comes and goes at the same time each year, usually starting with the onset of winter. People with seasonal affective disorder often experience fatigue and oversleeping, carbohydrate craving and weight gain, as well as an overly sad mood. More women have SAD than men, and children and teens can also experience SAD. SAD is linked to decreasing exposure to daylight that occurs naturally during the winter months. Studies have shown that when people with this form of depression travel south in winter, their symptoms improve, and when they travel north their symptoms worsen.

These findings have led to treatment with artificial light. With light therapy, people use bright grow-light type lights or special lightboxes for several hours each day. This therapy has shown good results, and research continues to investigate this form of depression.

How Is Depression Treated?

Treatment for depression depends on its type and severity. There are several approaches that can be used either alone or in combination. Current thinking suggests that medication combined with psychotherapy (sykoe-THER-a-pea) is the most effective treatment for moderate to severe depression. The medication helps relieve the symptoms of depression, while the psychotherapy helps people change their negative thought patterns.

Medication

Antidepressant (an-tie-dee-PRESS-ant) medication can be prescribed by a psychiatrist (a medical doctor who specializes in mental disorders) or another physician. People usually must take a medication for several weeks before they notice changes in their mood, and they typically continue to take the drug for 6 to 9 months. Antidepressants are not habit-forming. Not every medication works for every person, however.

One group of antidepressants, introduced in the 1980s, is called selective serotonin (ser-o-TOE-nin) reuptake inhibitors (SSRIs). Serotonin is a neurotransmitter in the brain, and these drugs work by altering brain chemistry. They generally have fewer side effects than other drugs used to treat depression. Examples of SSRIs include fluoxetine (brand name Prozac), paroxetine (Paxil), and sertraline (Zoloft). Other types of antidepressants, including groups of drugs called monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs), also can be helpful for some people.

Lithium (Eskalith, Lithobid) is a medication that can be very effective in treating bipolar disorder. However, lithium does not work for everyone. For these people, doctors sometimes prescribe another mood-stabilizing medication, such as carbamazepine (Tegretol) or divalproex sodium (Depakote).

St. Johns wort (Hypericum perforatum ) is an herb that is widely prescribed for mild depression in Europe. Although it is sold without a prescription in the United States, St. Johns wort has not been approved by the U.S. Food and Drug Administration for the treatment of depression, because not enough controlled studies have been done to show whether it is safe and effective. Those studies are currently underway.

Psychotherapy

Psychotherapy, or talking therapy, involves a therapeutic relationship between the depressed person and a psychiatrist, psychologist, or mental health counselor. Cognitive-behavioral (KOG-ni-tivbe-HAVE-yor-ul) therapy (CBT) and interpersonal (in-ter-PER-son-al) therapy (IPT) have been shown to be particularly useful. CBT focuses on helping people change their thoughts and actions. IPT helps people focus on resolving problems in relationships that may be triggers for depression.

Positron emission tomography (PET) records electrical activity inside the brain. With red and yellow showing brain activity, the brain of a depressed person at the top shows a decrease in activity compared to the brain of a person who has been treated for depression at the bottom. Treatment can improve metabolic acticity and blood flow in the brain. Photo Researchers, Inc.

Electroconvulsive (e-LEK-troe-kon-VUL-siv) therapy (ECT)

ECT, popularly known as shock therapy, is used to treat severe depression when immediate relief is needed. This treatment, which is performed by a physician, requires hospitalization and anesthesia to keep the person free of pain and injury. Carefully controlled electrical pulses are sent to the brain, causing a brief seizure. Although this treatment is controversial, it can be a lifesaver for someone who is suicidal and needs immediate relief.

Self-help groups

Many people experiencing depression find it helpful to join local support or self-help groups. These groups share information and tips for coping with depression. Some also offer support for close family members and friends.

Experiencing Depression

Sadly, about two-thirds of people who experience depression do not seek help. This is unfortunate, since the vast majority of people with depression can be helped to feel better in a relatively short time.

The best way to help someone with depression is to encourage that person to get professional help. If the depression is severe, encouragement may not be enough, however. It may be necessary to arrange a visit to a health care provider for them. Help is available through family physicians and health maintenance organizations, community mental health centers, hospitals, and mental health clinics. People who are talking about suicide need emergency care. Many telephone books list suicide and mental health crisis hotlines in their Community Service sections, or help can be obtained by calling emergency services (911 in most places).

Depression is not a sign of personal failure or something to be ashamed of. It does not mean that a person is crazy. Depression is simply an illness that needs to be treated so that life will once more be enjoyable, purposeful, and worthwhile.

See also

Bipolar Disorder

Brain Chemistry (Neurochemistry)

Genetics and Behavior

Seasonal Affective Disorder

Suicide

Therapy

Resources

Book

Styron, William. Darkness Visible: A Memoir of Madness. New York: Random House, 1990. A short book by the author of Sophies Choice about his battle with depression.

Organizations

American Psychiatric Association, 1400 K Street Northwest, Washington, DC 20005. A professional organization that provides information about depression on its website. Telephone 888-357-7924 http://www.psych.org

National Depressive and Manic-Depressive Association, 730 North Franklin Street, Suite 501, Chicago, IL 60610-7204. A national support organization for people with depression and bipolar disorder. Telephone 800-826-3632 http://www.ndmda.org/

U.S. National Institute of Mental Health, 6001 Executive Boulevard, Room 8148, MSC 9663, Bethesda, MD 20892-9663. A government agency that does research on depression and provides information to the public through pamphlets and a searchable website. Telephone 800-421-4211 http://www.nimh.nih.gov

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depression

depression Disorder characterized by feelings of guilt, failure, worthlessness or rejection. Frequently a response to a difficult life-situation, depression leads to low self-esteem, self-recrimination and obsessive thoughts. Insomnia, loss of appetite and lethargy are often present, and in severe cases there is a risk of suicide. See also manic depression

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depression

depression In meteorology, a region of low atmospheric pressure with the lowest pressure at the centre. It usually brings unsettled or stormy weather. See also cyclone

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Depression

DEPRESSION

DEPRESSION. SeeGreat Depression .

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"Depression." Dictionary of American History. 2003. Encyclopedia.com. 1 Jul. 2016 <http://www.encyclopedia.com>.

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