Depression

Constance Hammen, Ed Watkins

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781134870967
• Edition: 3
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

Depression provides a valuable and accessible resource for students, practitioners, and researchers seeking an up-to-date overview and summary of research-based information about depression. With the help of clinical examples, the authors present chapters covering the hypothesized causes of depression, including genetic and biological factors, life stress, family, and interpersonal contributors to depression.

The third edition extensively updates prior coverage to reflect advances in the field. The presumed causes of depression from both a biological perspective as well as from social and cognitive perspectives are explored in detail. Two chapters explore the most recent developments in pharmacological and biological interventions and in psychological treatments, as well as the prevention of depression. This new edition includes updated discussion about challenges in research, including heterogeneity and diagnosis of depression and proposed solutions, as well as the efficacy and availability of treatments.

Authored by experts in the field who are active researchers and clinicians, Depression provides a state-of-the-art primer for final year undergraduate and postgraduate students, clinicians, professionals, and researchers seeking a broad reference task that critically evaluates research into depression.

1
Defining and diagnosing depression

I had another tortured, sleepless night until nearly dawn and awoke with an instant of calm before I recognised the heaviness in my body and the sense of desolation about the coming day. I pushed myself out of bed and made myself go through the steps of getting ready for work. How can I make my deadened face smile at the boss, I wondered, and manage my tasks when I can barely concentrate? It’s hard to imagine that only a couple of months ago I was able to enjoy even the minutiae of the day and looked forward to spending time with friends and the family. Now I can barely remember when the world didn’t seem cast in shades of grey, and I felt able to enjoy a sunset or a sip of tea. My doctor tells me that it will get better with time, that depression lifts, but I am not sure that prediction will apply to me. I feel so alone, leaden and empty that I wonder if I can go on.

The words of this individual capture vividly the experience of depression, and its themes have also been echoed in ancient texts of the Bible, Greek, Roman and Chinese classics – as well as Shakespearean plays and Russian novels. Depression is a universal, timeless and ageless human affliction. However, while the personal experience of depression is profoundly painful, it is often misunderstood by others. Individuals in Western societies are often raised to expect to have considerable control over moods, and are exhorted not to let themselves suffer from depression. Thus, it is distressing to others when a loved one or friend does not ‘snap out’ of depression, and the hopeless, helpless and self-hating attitudes expressed by depressed individuals often seem illogical and irrational, as if the depressed person wilfully and perversely holds onto unreasonable moods and beliefs.

As this book hopes to explore, depression is neither uncommon nor particularly paradoxical – nor is it a failure of willpower and motivation. It is enormously impairing – and even deadly – and its effects on both the afflicted person and his or her family can be profoundly negative. Yet, we also have a number of effective treatments for depression and science is gaining considerable insight into the processes underpinning depression.

Phenomenology of depressive experiences

The term depression is used in everyday language to describe a range of experiences from a slightly noticeable and temporary mood decrease to a profoundly impaired and even life-threatening disorder. When used to describe a mood, the term conveys a temporary state of sadness and loss of energy or motivation that may last a few moments, hours, or even a few days. As such, it is usually a normal reaction to an upsetting event, or even an exaggerated description of a typical event (‘this weather is depressing’). A young man might feel sad for a few days following a romantic disappointment, or a woman might be discouraged for a few days upon being passed over for a job. Such experiences are not the topic of this book. Rather, the term ‘depression’ as used here refers to a constellation of experiences including not only mood, but also physical, mental and behavioural experiences that define more prolonged, impairing and severe conditions that may be clinically diagnosable as a syndrome of depression.

The description at the beginning of the chapter may differ from the personal experiences of other depressed people, but all share features of the syndromes of depression. Each sufferer has features from the four different domains that define depressive disorders. The four general domains are affect, cognition, behaviour and physical functioning.

Affective symptoms

Depression is one of several disorders generically called affective disorders, referring to the manifestations of abnormal affect or mood, as a defining feature. Thus, depressed mood, sadness, feeling low, down in the dumps or empty are typical. However, sometimes the most apparent mood is irritability (especially in depressed children). Moreover, not all depressed people manifest sadness or depression as such. Instead, they may report feeling loss of interest or pleasure, a feeling of ‘blah’, listlessness, apathy. Nothing seems enjoyable – not even experiences that previously elicited positive feelings, including work and recreation, social interactions, sexual activity and the like. Pastimes are no longer enjoyable; even pleasurable relationships with one’s family and friends may no longer hold appeal or even be negative, and the individual may find it hard to think of things to do that might help to relieve the depression even temporarily. Even when he or she accomplishes an important task, there is little sense of satisfaction. Some severely depressed people have described the loss of pleasure as seeing the world in black, white and grey with no colour. The experience of loss of interest or pleasure, called anhedonia, is one of the most common features of the depression syndrome, according to many studies of depressed adults and teenagers, from many different countries (reviewed in Klinger, 1993).

George, a middle-aged man of apparent good health, has felt listless and bored for a few weeks. His favourite television programmes are no longer of interest to him in the evenings, and on weekends he can’t think of anything to do that he imagines would be pleasurable – in contrast to his formerly active and fun-seeking self. He says his pals are ‘boring’ and his attitude about seeing his girlfriend is that she doesn’t interest him anymore. Fortunately, she is astute enough to suspect that he became depressed ever since someone else got the promotion at work that he hoped for – though George himself would deny that he is depressed.

Cognitive symptoms

Some have called depression a disorder of thinking, as much as it is a disorder of mood. Depressed people typically have negative thoughts about themselves, their worlds and the future. They experience themselves as incompetent, worthless and are relentlessly critical of their own acts and characteristics, and often feel guilty as they dwell on their perceived shortcomings. Low self-esteem is therefore a common attribute of depression. Individuals may feel helpless to manage their lives or resolve problems. They may view their lives and futures as bleak and unrewarding, feeling that change is not only pointless but essentially unattainable. Cognitions reflecting hopelessness about one’s ability to control desired outcomes may be common, and the resulting despair may also give rise to thoughts of wanting to die or to take one’s own life.

Annette has been increasingly depressed since her boyfriend went off to university. Although he keeps in touch with her, she is consumed with the thoughts that he is trying to meet other women, that she’s not good enough to sustain his interest – and indeed, why would anyone ever love her. At work she imagines that she is doing a poor job and expects to be fired – despite her boss’s praise for her achievements. When her girlfriends ask her to go out with them she believes that they don’t really want her company and are only feeling sorry for her that her boyfriend is away. As she becomes more and more depressed, she believes herself to be a horrible person; tasks at work seem more and more overwhelming so that she believes that she is incompetent and utterly helpless to figure out how to manage projects she used to do with ease.

The cognitive features of depression have been given particular emphasis by some investigators, who note that thinking in such self-critical ways actually makes people more depressed or prolongs their depression. This observation gave rise to Aaron Beck’s cognitive model of depression (Beck, 1967; Beck, 1976), which hypothesises an underlying vulnerability to depression due to tendencies to perceive the self, world and future in negative ways. The cognitive model of depression and related models are discussed in Chapter 5.

In addition to negativistic thinking, depression is often marked by difficulties in mental processes involving concentration, decision-making and memory. The depressed person may find it enormously difficult to make even simple decisions, and significant decisions seem beyond one’s capacity altogether. Depressed patients often report problems in concentrating, especially when reading or watching television, and memory may be impaired. Memory problems, in fact, often lead depressed people to worry further that their minds are failing, and in older depressed individuals what is actually a treatable memory deficit due to depression may be misinterpreted as a sign of irreversible dementia.

Behavioural symptoms

Consistent with the apathy and diminished motivation of depression, it is common for individuals to withdraw from social activities or reduce typical behaviours. In severe depression, the individual might stay in bed for prolonged periods. Social interactions might be shunned, both because of loss of motivation and interest, and also because depressed people perceive, fairly accurately, that being around them may be aversive to others.

Actual changes in motor behaviour are often observed, taking the form either of being slowed down or agitated and restless. Some depressed individuals may talk and move more slowly, their faces showing little animation with their mouths and eyes seeming to droop as if weighted down, all of which are labelled psychomotor retardation. Their speech is marked by pauses, fewer words, monotone voice and less eye contact (Buyukdura, McClintock and Croarkin, 2011; Schrijvers, Hulstijn and Sabbe, 2008). Other depressed people display psychomotor agitation, indicated by restlessness, hand movements, fidgeting, self-touching, and gesturing. Psychomotor agitation may be more commonly observed in depressed people who are also experiencing anxiety symptoms.

Physical symptoms

In addition to motor behaviour changes that are apparent in some depressed people, there may also be changes in appetite, sleep and energy. Reduced energy is a very frequent complaint. Depressed patients complain of list-lessness, lethargy, feeling heavy and leaden, and lacking the physical stamina to undertake or complete tasks.

Sleep disturbance is a particularly important symptom of depression, with the majority (60–84 per cent) of unipolar depressed patients reporting poorer quality of sleep, experienced as a loss of restfulness and/or a reduced duration of sleep (Benca, Obermeyer, Thisted and Gillin, 1992; Kupfer, 1995). Sleep changes can take several forms: difficulty falling asleep, staying asleep or too much sleep. Depressed people sometimes experience what is called ‘early morning awakening’, a problem of waking an hour or more before the regular awakening time, usually with difficulty falling back asleep.

The relationship between sleep disturbance and depression is a complex one, with a close correspondence existing between regulation of mood and regulation of sleep (Lustberg and Reynolds, 2000). There is robust evidence of a reciprocal relationship between insomnia and depression (Asarnow, Soehner and Harvey, 2014; Herrick and Sateia, 2016). As well as being an important consequence or complication of depression, impaired sleep also often precedes and predicts a subsequent episode of depression (Asarnow et al., 2014; Harvey, 2011).

Patients with depression also experience changes in appetite, typically in the form of decreased appetite with corresponding weight loss. However, some depressed people eat more when depressed, with this pattern often associated with increased sleep.

Implications

The multiplicity of symptoms of depression means that depressed people differ from one another in the manifestations of their disorder and in the particular combination, nature and severity of their symptoms. Such differences may reflect variability in the severity of the depression, as well as suggesting that there may be different forms of depression that have different causes and treatments. The diagnostic systems in use today define several categories that cut across these variabilities, and that represent the major forms of the disorder that are the basis of most research and clinical categorisation. However, there has also been considerable debate about the validity and utility of these diagnostic systems. Thus, this chapter will first present traditional approaches to diagnosis and then discuss their limitations and alternatives.

Diagnosis of depression

The first key diagnostic distinction is between unipolar depres...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of tables and figures
• 1 Defining and diagnosing depression
• 2 Course and consequences of depression
• 3 Who is affected by depression?
• 4 Biological aspects of depression
• 5 Cognitive and life stress approaches to depression
• 6 Social aspects of depression
• 7 Biological treatment of depression
• 8 Psychological treatments
• Index