A term paper on the psychological aspects of Depression

What is depression?

Being clinically depressed is very different from the down type of feeling that all people experience from time to time. Occasional feelings of sadness are a normal part of life, and it is unfortunate that such feelings are often colloquially referred to as "depression." In clinical depression, such feelings are out of proportion to any external causes. There are things in everyone's life that are possible causes of sadness, but people who are not depressed manage to cope with these things without becoming incapacitated.
As one might expect, depression can present itself as feeling sad or "having the blues". However, sadness may not always be the dominant feeling of a depressed person. Depression can also be experienced as a numb or empty feeling, or perhaps no awareness of feeling at all. A depressed person may experience a noticeable loss in their ability to feel pleasure about anything. Depression, as viewed by psychiatrists, is an illness in which a person experiences a marked change in their mood and in the way they view themselves and the world. Depression as a significant depressive disorder ranges from short in duration and mild to long term and very severe, even life threatening.
Depressive disorders come in different forms, just as do other illnesses such as heart disease. The three most prevalent forms are major depression, dysthymia, and bipolar disorder.

What is major depression?
Major depression is manifested by a combination of symptoms (see symptom list below) that interfere with the ability to work, sleep, eat; and enjoy once-pleasurable activities. These disabling episodes of depression can occur once, twice, or several times in a lifetime.

What is dysthymia?
A less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep you from functioning at "full steam" or from feeling good. Sometimes people with dysthymia also experience major depressive episodes.

What is bipolar depression (manic-depressive illness)?
Another type of depressive disorder is manic-depressive illness, also called bipolar depression. Not nearly as prevalent as other forms of depressive disorders, manic depressive illness involves cycles of depression and elation or mania. Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, you can have any or all of the symptoms of a depressive disorder. When in the manic cycle, any or all symptoms listed under mania may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, unwise business or financial decisions may be made when in a manic phase


What is Seasonal Affective Disorder (SAD)?
SAD is a pattern of depressive illness in which symptoms recur every winter. This form of depressive illness often is accompanied by such symptoms as marked decrease in energy, increased need for sleep, and carbohydrate craving. Photo therapy - morning exposure to bright, full spectrum light - can often be dramatically helpful.



What is Post Partum Depression?
Mild moodiness and "blues" are very common after having a baby, but when symptoms are more than mild or last more than a few days, help should be sought. Post part depression can be extremely serious for both mother and baby.

How is bereavement different from depression?
A full depressive syndrome frequently is a normal reaction to the death of a loved one (bereavement), with feelings of depression and such associated symptoms as poor appetite, weight loss, and insomnia. However, morbid preoccupation with worthlessness, prolonged and marked functional impairment, and marked psychomotor retardation are uncommon and suggest that the bereavement is complicated by the development of a Major Depression. The duration of "normal" bereavement varies considerably among different cultural groups.

What is Endogenous Depression?
A depression is said to be endogenous if it occurs without a particular bad event, stressful situation or other definite, outside cause being present in the person's life. Endogenous depression usually responds well to medication. Some authorities do not consider this to be a useful diagnostic category.

What is atypical depression?
"Atypical depression" is not an official diagnostic category, but it is often discussed informally. A person suffering from atypical depression generally has increased appetite and sleeps more than usual. An atypical depressive may also be able to enjoy pleasurable circumstances despite being unable to seek out such circumstances. This contrasts with the "typical" depressive, who generally has reduced appetite and insomnia, and who is often unable to find pleasure in anything. Despite its name, atypical depression may in fact be more common than the other kind.










What are the typical symptoms of depression?
A depressive disorder is a "whole-body" illness, involving your body, mood, and thoughts. It affects the way you eat and sleep, the way you feel about yourself, and the way you think about things. A depressive disorder is not a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help over 80% of those who suffer from depression. Bipolar depression includes periods of high or mania. Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Also, severity of symptoms varies with individuals.
Symptoms of Depression:
· Persistent sad, anxious, or "empty" mood
· Feelings of hopelessness, pessimism
· Feelings of guilt, worthlessness, helplessness
· Loss of interest or pleasure in hobbies and activities that you once enjoyed, including sex
· Insomnia, early-morning awakening, or oversleeping.
· Appetite and/or weight loss or overeating and weight gain
· Decreased energy. fatigue, being "slowed down"
· Thoughts of death or suicide, suicide attempts
· Restlessness, irritability
· Difficulty concentrating, remembering, making decisions
· Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain
Symptoms of Mania:
· Inappropriate elation
· Inappropriate irritability
· Severe insomnia
· Grandiose notions
· Increased talking
· Disconnected and racing thoughts
· Increased sexual desire
· Markedly increased energy
· Poor judgment
· Inappropriate social behavior





What are the diagnostic criteria for depression?
Depression comes in many forms and in many degrees. Below, you will find some of the most common depressive types, along with some of the diagnostic criteria from the DSM-III-R (the official diagnostic and statistical manual for psychiatric illnesses).
Major Depression:
This is a most serious type of depression. Many people with a major depression can not continue to function normally. The treatments for this are medication, psychotherapy and, in extreme cases, electroconvulsive therapy (ECT).
Diagnostic criteria:
At least five of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either
· depressed mood, or
· loss of interest or pleasure. (Do not include symptoms that are clearly due to a physical condition, mood-incongruent delusions or hallucinations, incoherence, or marked loosening of associations.)
depressed mood most of the day, nearly every day, as indicated either by subjective account or observation by others
markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation by others of apathy most of the time)
significant weight loss or weight gain when not dieting (e.g. more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
diminished ability to think or concentrate, or indecisiveness nearly every day (either by subjective account or as observed by others)
recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
It cannot be established that an organic factor initiated and maintained the disturbance. The disturbance is not a normal reaction to the death of a loved one.
At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms (i.e. before the mood symptoms developed or after they have remitted).
Not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder.
Dysthymia:
This is a mild, chronic depression which lasts for two years or longer. Most people with this disorder continue to function at work or school but often with the feeling that they are "just going through the motions". The person may not realize that they are depressed. Anti-depressants or psychotherapy can help.
Diagnostic criteria:
Depressed mood (or can be irritable mood in children and adolescents) for most of the day, more days than not, as indicated either by subjective account or observation by others, for at least two years (one year for children and adolescents)
Presence, while depressed, of at least two of the following:
poor appetite or overeating
insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor concentration or difficult making decisions
feelings of hopelessness
During a two-year period (one-year for children and adolescents) of the disturbance, never without the symptoms in '1.' for more than two months at a time.
No evidence of an unequivocal Major Depressive Episode during the first two years (one year for children and adolescents) of the disturbance.
Has never had a Manic Episode or an unequivocal Hypomanic Episode.
Not superimposed on a chronic psychotic disorder, such as Schizophrenia or Delusional Disorder.
It cannot be established that an organic factor initiated or maintained the disturbance, e.g., prolonged administration of an antihypertensive medication.
Adjustment Disorder with Depressed Mood:
This is the type of depression that results when a person has something bad happen to them that depresses them. For example, loss of one's job can cause this type of depression. It generally fades as time passes and the person gets over what ever it was that happened.
Diagnostic criteria:
A reaction to an identifiable psycho social stressor (or multiple stressors) that occurs within three months of onset of the stressor(s).
The maladaptive nature of the reaction is indicated by either of the following:
· impairment in occupational (including school) functioning or in usual social activities or relationships with others
· symptoms that are in excess of a normal and expectable reaction to the stressor(s)
The disturbance is not merely one instance of a pattern of overreaction to stress or an exacerbation of one of the mental disorders previously described (in the entire DSM).
The maladaptive reaction has persisted for no longer than six months.
The disturbance does not meet criteria for any specific mental disorder and does nor represent Uncomplicated Bereavement.


How do you know when depression is severe enough that help should be sought?
Professional help is needed when symptoms of depression arise without a clear precipitating cause, when emotional reactions are out of proportion to life events, and especially when symptoms interfere with day-to-day functioning.. Professional help should definitely be sought if a person is experiencing suicidal thoughts.













































What causes depression?
The group of symptoms which doctors and therapists use to diagnose depression ("depressive symptoms"), which includes the important proviso that the symptoms have manifested for more than a few weeks and that they are interfering with normal life, are the result of an alteration in brain chemistry. This alteration is similar to temporary, normal variations in brain chemistry which can be triggered by illness, stress, frustration, or grief, but it differs in that it is self-sustaining and does not resolve itself upon removal of such triggering events (if any such trigger can be found at all, which is not always the case.)
Instead, the alteration continues, producing depressive symptoms and through those symptoms, enormous new stresses on the person: unhappiness, sleep disorders, lack of concentration, difficulty in doing one's job, inability to care for one's physical and emotional needs, strain on existing relationships with friends and family. These new stresses may be sufficient to act as triggers for continuing brain chemistry alteration, or they may simply prevent the resolution of the difficulties which may have triggered the initial alteration, or both.
The depressive brain chemistry alteration seems to be self-limiting in most cases: after one to three years, a more normal chemistry reappears, even without medical treatment. However, if the alteration is profound enough to cause suicidal impulses, a majority of untreated depressed people will in fact attempt suicide, and as many as 17% will eventually succeed. Therefore, depression must be thought of as a potentially fatal illness. Friends and relatives may be deceived by the casual way that profoundly depressed people speak of suicide or self-mutilation. They are not casual because they "don't really mean it"; they are casual because these things seem no worse than the mental pain they are already suffering. Any comment such as, "You'd be better off if I were gone," or "I wish I could just jump out a window," is the equivalent of a sudden high fever; the depressed person must be taken to a professional who can monitor their danger. A formulated plan, such as, "I'm going to jump in front of the next car that comes by," is the equivalent of sudden unconsciousness: an immediate medical emergency which may require hospitalization.
Depression can shut down the survival instinct or temporarily suppress it. Therefore, depressed suicidal thinking is not the same as the suicidal thinking of normal people who have reached a crisis point in their lives. Depressive suicides give less warning, need less time to plan, and are willing to attempt more painful and immediate means, such as jumping out of a moving car. They may also fight the impulse to suicide by compromising on self-injury -- cutting themselves with knives, for example, in an attempt to distract themselves from severe mental pain. Again, relatives and friends are likely to be astonished by how quickly such an impulse can appear and be acted upon.

What initiates the alteration in brain chemistry?
It can be either a psychological or a physical event. On the physical side, a hormonal change may provide the initial trigger: some women dip into depression briefly each month during their premenstrual phase; some find that the hormone balance created by oral contraceptives disposes them to depression; pregnancy, the end of pregnancy, and menopause have also been cited. Men's hormone levels fluctuate as deeply but less obviously.
It is well known that certain chronic illnesses have depression as a frequent consequence: some forms of heart disease, for example, and Parkinsonism. This seems to be the result of a chemical effect rather than a purely psychological one, since other, equally traumatic and serious illnesses don't show the same high risk of depression.

Is a tendency to depression inherited?
It seems there are some people whose brain chemistry is predisposed to the depressive response, and others who are at much lower risk of depression even if exposed to the same physical or psychological triggers. The genetic relations of manic-depressives are at a higher risk for uni-polar depression than the population at large or their adopted/by marriage relations. There seems to be a link between high creativity and the gene for manic-depression: artists and writers often are not manic-depressive themselves, but have a family member who is. Studies of families in which members of each generation develop manic-depressive illness found that those with the illness have a somewhat different genetic make-up than those who do not get ill. However, the reverse is not true: not everybody with the genetic make-up that causes vulnerability to manic-depressive illness has the disorder. Apparently additional factors, possibly a stressful environment, are involved in its onset.
Major depression also seems to occur, generation after generation, in some families. However, depression can occur in people with no family history of any form of mental illness. And I would be reluctant to suggest that there is any human who is entirely immune to depression under all possible conditions.
Psychological triggers: many, if not most, people with depression can point to some incident or condition which they believe is responsible for their unhappiness. Of course, people with severe depression are prone to astonishingly virulent and inappropriate guilt and self-hatred.
The (genuine) life events that most often appear in connection with depression are various, but there is one distinguishing feature that appears in many cases, over and over: loss of self-determination, of empowerment, of self-confidence. More profoundly: a loss of self, of the abilities or activities that a person identifies with herself. Stereotypically: a man loses the job that had defined him to himself and others, whether that definition was "executive" or "breadwinner"; a woman who had spent her whole life preparing for and living the role of wife, supporter, caretaker, is suddenly left alone by divorce or death. In general, any life change, often caused by events beyond one's control, which damages the structure that gave life meaning.
The ability of a person to respond to such an event will depend on many factors, including genetic predisposition, support from friends, physical health, even the weather. It can also depend on internal psychological factors which may best be explored in talk therapy: why is the person's self-esteem so bound up in the position or state that has been lost? Can she find a new source of self-esteem? Therapy can be immensely helpful here.
Obviously, not everyone to whom this sort of event happens becomes depressed, and not every person who becomes depressed has had this sort of catastrophe befall them. In fact, if a person suffers a loss and then becomes depressed, it may well be that they weathered the loss in fine style and then succumbed to a much less obvious trigger, psychological or physical.
Some depressions may well be caused by a spontaneous aberration in brain chemistry, with no trigger that we can currently identify, just as a seizure or migraine may have an obvious trigger or be apparently spontaneous.
However, once the depressive state has set in, both physical and psychological problems will be generated in abundance. What faster way to lose a job or a spouse than to be too depressed to work or to communicate? What worse psychological state for coping with a blow to identity can there be than a chemically promoted, pathological self-hatred? And what can be worse for self-esteem than watching one's appearance and household disintegrate as one loses the motivation to shower, straighten up, wash dishes or laundry, or choose attractive clothes? Health deteriorates as well: some depressed people can't sleep or eat, others sleep constantly (a real help on the job!) and eat incessantly, sometimes in order to stay awake, sometimes because it's the only thing that gives a little pleasure or comfort. (Carbohydrates induce production of serotonin, so there may be an element of self-medication here.) Almost no one has the impulse to exercise or get fresh air and sunshine. Most if not all of these effects form feedback loops, increasing in magnitude and becoming triggers for further depression.


































How do antidepressants relieve depression?
A. There are several classes of antidepressants, all of which seem to work by increasing levels of certain neurotransmitters (most commonly serotonin, norepinephrine, and dopamine) in the brain. It is not entirely clear why increasing neurotransmitter levels should reduce the severity of a depression. One theory holds that the increased concentration of neurotransmitters causes changes in the brain's concentration of molecules, receptors, to which these transmitters bind. In some unknown way it is the changes in the receptors that are thought responsible for improvement.

Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug?
There are very few kinds of depression for which there are specific antidepressant treatments. When it comes to people with Bipolar Disorder who are depressed there are some major problems. Most importantly, with any antidepressant, there is a possibility that the antidepressant treatment will cause depressed bipolar people not just to come out of their depressions, but to develop manic episodes. The possibility of an antidepressant causing mania is least when the antidepressant is bupropion (Wellbutrin). The possibility of mania is greatly reduced if depressed bipolar folks are on a mood stabilizer such as lithium, Tegretol or Depakote when they are started on an antidepressant.

What percentage of depressed people will respond to antidepressants?
A. Generally, about 2/3 of depressed people will respond to any given antidepressant. People who do not respond to the first antidepressant they have taken, have an excellent chance of responding to another.