Applied Aspects of Depression Research Paper

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The term depression can be used in a number of ways. As commonly used, it refers to a normative, usually transient and generally dejected, dispirited, or sad mood state. It can also be a symptom related to several emotional or physical disorders. It can refer to a syndrome (a collection of symptoms that usually occur together) and is also used as the official name for a specific mental disorder in the current psychiatric nomenclature. As the latter, depression is considered to be a psychopathological entity hypothesized to have distinctive etiological mechanisms, prognosis, and treatment implications. This research paper describes these types of depression, discusses the prevalence of the more common types studied, and presents prevention, treatment, and maintenance interventions currently suggested for persons with depression. The final section examines the concept of healthy mood management from a developmental perspective.

Outline

I. Types of Depression

A. Depressed Mood

B. Depression as a Symptom

C. Depression as a Syndrome

D. Depressive Disorders

II. Depression as a Disorder

A. Major Depression

B. Dysthymia

C. Bipolar Disorder

III. Prevention of Depression

A. Levels of Preventive Intervention

1. Universal Preventive Interventions

2. Selective Preventive Interventions

3. Indicated Preventive Interventions

B. Attributable Risk

IV. Treatment of Major Depression

V. Maintenance

VI. Healthy Mood Management: A Developmental Perspective

VII. Conclusion

I. Types of Depression

A. Depressed Mood

Depressed mood states appear to be a normal part of human subjective experience. Most individuals have a personal understanding of depressed mood, in contrast with, say, psychotic experiences or addictions. Depressed mood states usually involve the emotion of sadness, a subjective lack of energy, reduced motivation to engage in formerly pleasant activities, reduced desire to have positive interactions with other people, and a belief that one’s lot in life is difficult. Such states color one’s reactions to external events, but they can themselves be modified by such events. Normal states of depressed mood last hours or days. Once they become more chronic and start affecting one’s ability to function, they are often conceptualized as part of a pathological process, which can ultimately meet criteria for a diagnosis of a clinical depressive disorder.

It is useful to examine the relationship between emotions, such as sadness, and mood states. Emotion researchers generally conceptualize emotions as relatively short-lived reactions to external or internal stimuli. These reactions appear to be relatively autonomous, that is, not ordinarily subject to conscious planning. They have physiological, expressive, and subjective elements. They usually occur within seconds of the triggering stimulus and last on the order of minutes. As the subjective feeling which is part of an emotional response lasts longer, it can become a mood state. Alternatively, the emotion can fade away or change into a different emotion; for example, in response to being surprised, one can exhibit a startle response, then fear, anger, and finally amusement and relief. The trigger for these kinds of changes can be external (the availability of new information) as well as internal (the subjective interpretation of the new information).

Although, under normal circumstances, the initial emotional response to specific triggers appears to be too quick to be under conscious control, once the emotion begins to develop, the modulation of the emotional response does seem to be amenable to planned influences. Part of the developmental process in humans involves the regulation of emotion. Maturity is judged in part on the individual’s ability to control his or her emotional responses.

The role of mood states in the development of psychopathology has yet to be adequately elucidated. It is well known that prior to having a major depressive episode, there is usually a period of gradually increasing depressed mood and symptoms. If these symptoms develop into a major depressive episode, they are retrospectively considered a prodrome of the clinical episode. However, most individuals with high depressive symptoms do not go on to a clinical episode of depression. It may be that naturally occurring events in daily life may increase or decrease the probability of pathological depression. Or perhaps different coping mechanisms, when put into practice, afford differential degrees of protectiveness. Alternatively, it may be that those who are predisposed, because of genetic or other biological factors, are the ones who are most likely to fall prey to the pathological process. As of now, the answers to these questions are not yet in.

B. Depression as a Symptom

Depression can be viewed as a dichotomous concept: it is present or it is not. It can also be conceptualized as a continuum: one can be more or less depressed. The former conceptualization is compatible with the disorder view of depression, and is covered later. The latter concept has been much used in epidemiologic studies and in clinical studies, particularly in those focused on treatment outcome. The general strategy for measuring the level of depression that an individual is experiencing has been to construct a questionnaire or a structured interview that inquires about several aspects of the depressive state, usually focus ing on duration and/or intensity of several symptoms of depression. The questionnaire or interview is then scored, yielding a single continuous variable. Higher scores reflect a greater level of depression. Depression symptom scales have been useful in providing normative data on the experience of depression in community samples and in helping to evaluate the effect of treatment on level of depression. Depression symptom scales are usually not intended to diagnose depression.

Epidemiological studies provide evidence that depressive symptoms are prevalent in the general population. High levels of depressive symptomatology, as measured by self-report symptom scales, have sometimes been referred to as demoralization. Demoralization appears to be more prevalent in low-income minority populations than in white middle-class samples. It is unclear whether the difference is due primarily to ethnicity or to social class, but the preponderance of the evidence indicates that when controls are implemented for socioeconomic factors, the differences in depression levels diminish or disappear.

The interpretation of similar differences in depression scores showing higher levels for women has also been controversial. Disentangling the role of socioeconomic issues between men andwomen is much harder, because married women, especially those who do not have a paying job outside the home, are generally assigned their husband’s social class, even though they may not have the same type of independence or control over resources that their husbands do.

The relationship between age and depressive symptoms is not clear. Most studies have found no difference, others have found higher rates in younger persons, and still others found higher rates in older persons.

There is a relatively clear connection between depressed symptoms and substance abuse. Studies of national samples have found that individuals with negative mood states, including depression, are more likely to use cigarettes and alcohol. They are also less likely to quit smoking, and if they quit, are more likely to relapse. The direction of causality is not easy to disentangle, however. Use of drugs, including alcohol, can increase the likelihood of depressed states. The physiological effects of drugs on the nervous system is probably implicated in this process, but it is also true that the disruption to the individual’s life caused by drug abuse probably produces significant psychological stress.

C. Depression as a Syndrome

Major depressive episode is the most common depressive syndrome.Asyndrome is a configuration of symptoms that often occur together and constitute a recognizable condition. Although the presence of a major depressive syndrome is a necessary characteristic of major depressive disorder, it is not sufficient. The syndrome can occur for other reasons. For example, medications or drugs of abuse, as well as general medical conditions, can have direct physiological effects which can trigger the symptoms of a major depressive episode. Similarly, the loss of a loved one can result in this configuration of symptoms. In the latter case, unless the symptoms persist for longer than 2 months, or produce marked functional impairment, suicidality, or psychosis, they are considered to be part of the normal course of bereavement.

The implication is that major depressive syndrome is much more prevalent than major depressive disorder. Currently, major depressive disorder is conceptualized as a clinical entity that may have genetic, other biological, and psychosocial sources, much like a specific illness. Major depressive syndrome is a condition that may be triggered by specific life events or by physical influences on the body, but it does not necessarily imply an underlying psychopathological process. These assumptions reflect a basic dilemma in the mental health field, namely, whether there is a qualitative difference between ‘‘normal’’ conditions (such as depressed mood or major depressive syndrome) and the officially recognized mental disorders (such as major depressive disorder), or whether the latter are merely quantitatively more intense and longer lasting manifestations of normal mood fluctuations.

D. Depressive Disorders

The most commonly used diagnostic system in the United States is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Depression is implicated primarily in what are termed the mood disorders. The mood disorders are themselves divided into two major categories: the depressive disorders and the bipolar disorders.Thedepressive disorders are sometimes referred to as unipolar depressions, that is, mood disorders in which changes from normal mood occur in only one direction, toward depressed mood. Bipolar disorders exhibit bidirectional fluctuations, either to depressed mood or to abnormally euphoric (manic) mood states. It is recognized that mood disorders can be the result of general medical conditions as well as the result of the use or abuse of drugs and other substances. Mood disorders caused by drug use or abuse are not considered primary mood disorders. In the following section, the DSM-IV diagnostic criteria for the more common mood disorders are presented.

II. Depression as a Disorder

A. Major Depression

Major depression is the most common of the mood disorders. The key diagnostic criterion for major depressive disorder is the presence of a major depressive episode.

There are nine symptoms that define a major depressive episode. Of the nine, at least five must have been present during a 2-week period. They must represent a change from previous functioning and they must cause significant impairment in daily functioning. At least one of the five symptoms must be either the first or the second symptom in the following list:

1. Depressed mood most of the day, nearly every day
2. Reduced interest or pleasure in all or almost all activities
3. Significant weight loss or weight gain, or a significant decrease or increase in appetite
4. Trouble sleeping or sleeping too much
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feeling worthless or guilty in an excessive or inappropriate manner
8. Problems in thinking, concentrating, or making decisions
9. Recurrent thoughts of death, suicidal ideation, specific suicidal plan, or a suicide attempt

B. Dysthymia

Dysthymia differs from major depression in that it is generally more chronic and is defined by fewer symptoms. The DSM-IV criteria for dysthymic disorder include a depressed mood for most days for at least 2 years in adults or at least 1 year in children and adolescents. In addition, two or more of the following six symptoms must be present: poor appetite or overeating, trouble sleeping or sleeping too much, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. The initial 2-year period must not have included a major depressive episode and the 2-year period of depression must not have been broken by a period of normal mood lasting more than 2 months.

C. Bipolar Disorder

Depressed mood and a major depressive episode may be part of bipolar disorders. However, what characterizes bipolar disorders is the occurrence of one or more manic episodes. The DSM-IV criteria for manic episode include a period of abnormally elevated, expansive, or irritable mood lasting at least 1 week, plus three or more of the following seven symptoms:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressured to keep talking
4. Flight of ideas or racing thoughts
5. Distractibility
6. Marked increased in goal-directed activity or psychomotor agitation
7. Excessive involvement in pleasurable activities with a high potential for painful consequences

There are two subtypes of bipolar disorders: Bipolar I involves full-blown manic episodes, and Bipolar II involves less intense, manic-like episodes, known as hypomanic episodes. There is also a bipolar disorder that parallels dysthymia, called cyclothymia. It is a chronic disorder that is characterized by the presence of both hypomanic periods and depressive periods most of the time for at least 2 years. Both depressive and bipolar disorders include residual categories called, respectively, ‘‘depressive disorder not otherwise specified’’ and ‘‘bipolar disorder not otherwise specified.’’ In both cases, the disorders do not meet the full criteria for either depressive or bipolar diagnoses.

III. Prevention of Depression

In its major 1994 report, Reducing Risks for Mental Disorders, the Institute of Medicine put forward a framework for mental health interventions that has three major levels: prevention, treatment, and maintenance. The most commonly known level of intervention is the treatment of acute cases of mental disorders. The Institute of Medicine also wanted to highlight the need for interventions that occur before the onset of the disorder, namely, preventive interventions, and interventions that occur after an acute episode has ended, that is, ‘‘maintenance’’ interventions intended to reduce relapse or recurrence or to help the individual regain the highest possible level of functioning. Each of these three levels is divided into the following subcategories.

A. Levels of Preventive Intervention

1. Universal Preventive Interventions

Universal preventive interventions for mental disorders are targeted to the general public or to a whole population group that has not been identified on the basis of individual risk. These interventions are believed to have a preventive effect on the population as a whole, and are believed to be protective of several types of psychological disorders. In general, such interventions should be of relatively low cost and easily disseminated.

2. Selective Preventive Interventions

Selective preventive interventions for mental disorders are targeted to subgroups of the population whose risk of developing mental disorders is significantly higher than average. Risks factors used to identify these groups may be biological, psychological, or social. The important factor is that they are associated with the onset of a mental disorder. Selective interventions could include interventions targeted to widows, people who are getting married for the first time, children going into the school system or graduating from the school system, individuals who have been laid off from work, women about to have their first child, or victims of trauma.

3. Indicated Preventive Interventions

Indicated preventive interventions are targeted to highrisk individuals who are identified as having minimum but detectable signs or symptoms foreshadowing a mental disorder or who have biological markers indicating predisposition for mental disorders. As in all of the preventive interventions, the individuals or groups targeted do not meet the full diagnostic criteria for the particular disorder being prevented at the time of being recruited into a preventive intervention program.

B. Attributable Risk

To engage in preventive interventions, one must identify the risk and/or protective factors that increase or decrease the probability of developing a particular disorder. An important concept from epidemiology is that of attributable risk. Attributable risk refers to the proportion of cases of a specific condition or disorder that are attributable to a specific factor. For instance, it is commonly known that tobacco smoking is related to lung cancer. However, lung cancer can also be caused by other factors. If we were to eradicate tobacco, a large proportion of lung cancer would be prevented, but not all cases. The proportion prevented would be the proportion of cases attributable to smoking, or the attributable risk.
Many factors have been linked to depression. Some of them are demographic factors that cannot be changed for the individual, such as sex, death of a parent during early childhood, or a family history of the disorder. Therefore it is important to focus on modifiable risk factors, especially those with a high level of attributable risk. From a preventive standpoint, one possible risk factor that is related to later episodes of major depression is the evidence of deficits in mood regulation. A potential strategy, therefore, is to identify individuals who have high symptom levels of depression, but who do not meet the criteria for a depressive disorder, and to teach such individuals methods to manage their moods. Such methods can come, for example, from cognitive–behavioral techniques that have been found to be useful in the treatment of depression. Some studies have already shown that depressive symptoms can be reduced in nonclinical populations that nevertheless show high depressive symptom levels when recruited. As of this writing, there have not been enough randomized controlled prevention trials to be able to say conclusively that new cases of major depression can be prevented. The development and evaluation of preventive interventions for depression and other mental disorders may be the next important stage in the development of mental health interventions.

IV. Treatment of Major Depression

Treatment interventions are divided into two sublevels: (1) case identification, to provide early treatment for cases of major depression that have not been identified previously; and (2) standard treatment, which accounts for the bulk of mental health intervention efforts.

The need for case identification efforts arises from the underdiagnosis of major depression and other depressive disorders in primary care clinics. Only 20% of individuals who meet criteria for major depression seek mental health services. However, more than 70% of those who meet criteria for major depression do seek health care, generally from a primary care physician. Yet, only about a third of individuals with major depression are so identified by their primary care providers. It is imperative, therefore, that primary care physicians and other health care providers learn to identify cases of depression so that individuals suffering from them may receive appropriate interventions.

Major depression is eminently treatable. Between 60% and 80% of individuals with major depression respond to either psychological or pharmacological treatments. Other less common types of treatment, such as light therapy and electroconvulsive therapy, have also been found effective for certain cases of major depression.

Treatments for depression vary in their theoretical assumptions and in the specific interventions used with patients. Certain common elements include an explicit helping relationship between the therapist and the patient, the identification of depression as a clinical disorder that requires treatment (as opposed to some type of ‘‘personal weakness’’), an explanatory framework for the mechanisms that trigger and maintain the depression, and implicit or explicit recommendations for patient behaviors that are expected to bring about improvement.

Many types of psychological approaches are currently used in the treatment of depression. Those that have been most often subjected to randomized controlled outcome trials are the cognitive–behavioral therapies. Cognitive–behavioral therapies for depression are based on the hypothesis that mood is influenced by a person’s cognitive and behavioral patterns. These patterns have been learned, usually in a social context, and can be modified. The purpose of therapy is to work with the patient to identify the cognitions (thoughts, assumptions, other mental processes) and behaviors (activity levels, interpersonal skills, and other physical or observable actions) that are most related to specific mood states. The goal of therapy is to reduce cognitions and behaviors that increase the probability of depressed states and augment those that decrease the probability of depression.

Another psychological approach to depression that has been repeatedly evaluated in randomized trials is interpersonal psychotherapy. This approach focuses on the influence that the interpersonal context has on triggering and maintaining depressive mood. The therapist reviews with the patient current and past interpersonal relationships as they relate to depressive symptoms. The focus of therapy usually centers on one or more of four major areas: grief, interpersonal disputes, role transitions, and interpersonal deficits.

Other psychological treatments have not been studied as extensively. However, brief approaches to therapy that specifically target depression have generally shown encouraging results.

Pharmacotherapy for depression has also been subjected to many randomized controlled trials. There are several types of antidepressants, all of which have approximately the same efficacy. Those developed most recently tend to have fewer side effects and lower lethality if used to attempt suicide. Pharmacotherapy is probably the most commonly used form of evidencebased treatment for depression in the United States, in part, because it is much more available than the psychotherapies. Antidepressants are prescribed at least as often by nonpsychiatric physicians as by psychiatrists. This has led to a strong (and controversial) emphasis on educating primary care providers to detect and treat depression in their setting before referring to mental health care providers.

Results of randomized trials do not always agree. Nevertheless, the preponderance of the evidence indicates that pharmacotherapy, cognitive–behavioral therapy, and interpersonal psychotherapy are all significantly effective in the treatment of major depression. The rate of improvement is generally faster for pharmacotherapy, but total improvement over a 20- week treatment is generally comparable across treatments, especially for mild and moderate cases of major depression. There appears to be some advantage to pharmacotherapy for more severe cases of depression, and clearly so for cases of depression with psychotic features in which antidepressants and antipsychotics may be prescribed simultaneously. A combination of psychotherapy and pharmacotherapy is often used in the treatment of depression. Most controlled studies have shown either additional improvement or no detectable difference in efficacy when both treatments are used. There appears to be no general disadvantage to the use of combined treatment. A major problem with treatment for depression is the high rate of relapse. This leads to a focus on maintenance strategies.

V. Maintenance

The third large segment of mental health interventions identified by the Institute of Medicine is the area of maintenance. Even though the treatment of acute episodes of depression and other disorders may be quite effective, relapse or recurrence of such an episode can be not only as disruptive as the first experience of clinical depression, but, at times, even more demoralizing. The fear that this painful condition will recur can have a major impact on a person’s outlook. Approximately 50% of persons who have had one major depressive episode have a second; 70% of those with two have a third; and 90% of those with three have a fourth. These figures suggest two important goals for the mental health field: preventing the first episode (as described earlier) and, if the first episode occurs, providing interventions that will maintain a healthy mood state, thus forestalling relapse and recurrence.

Current convention uses the terms relapse and recurrence in relatively well-defined ways. When treatment with antidepressants is effective, depressive symptoms diminish within a few weeks. In the 1980s, it was found that if antidepressant therapy was ended, a large proportion of patients began to exhibit symptoms again. The conclusion was that the processes underlying the mood dysregulation were still active, but that the medication was able to control the symptoms. Once medication ended, the symptoms reappeared. This reappearance was thought to be part of the same episode of depression. Now, the reappearance of symptoms within a year of the start of the episode is called relapse. Once the person has been free of clinical symptoms of depression for a year or more, the depressive episode is considered to be over. If symptoms reappear in the future, such an event is a recurrence.

Studies in which individuals who respondedwell to pharmacotherapy were followed for 1 or 2 years after treatment ended have found rates of relapse or recurrence as high as 70%. This has led to the recommendation that pharmacotherapy be continued for several months, and perhaps years, after the acute depressive episode has subsided. Some clinicians now state that for certain patients, lifetime maintenance pharmacotherapy is indicated.

Similar studies in which individuals who responded well to cognitive therapy have been followed have found much lower relapse rates of approximately35% after 1 or 2 years. This has led to speculation that cognitive therapy may have an advantage in terms of reducing relapse or recurrence rates. More studies designed specifically to answer this question are needed.

What is clear at this time is that individuals who have had a depressive episode are at high risk for repeated episodes of clinical depression. These individuals should be taught to monitor their mood state and to obtain treatment as soon as possible after the onset of significant depressive symptoms in the future.

VI. Healthy Mood Management: A Developmental Perspective

The development of effective mood management is an essential aspect of individual human growth. It is also a major factor in the health of a community. Among the major causes of death are several causes that appear to be influenced by mood problems. The top nine preventable causes of death, which account for about one half of all deaths in the United States, are tobacco, diet and exercise patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles, and illicit use of drugs. Consider for a moment how many of these might be exacerbated by depressed mood.

The relationship between negative mood states and smoking and drinking has already been described. It is highly likely that illicit use of drugs follows a similar pattern. Diet and exercise certainly are affected by depressed mood. Deaths from firearms present an interesting illustration of how strong, and yet invisible to most of us, the impact of depression is on our society: few people are aware that for several decades over half the deaths from firearms in the United States have been suicides. Unprotected sexual behavior not only exposes individuals to sexually transmitted diseases, but also to unplanned pregnancies. And some proportion of motor vehicle accidents are related to alcohol and other substance abuse, or to reckless driving, which may be the result of desperate states of mind. The proportion of these factors that is attributable to depression is yet unknown, but is likely to be significant.

Many factors have been implicated in the development of deficits in emotion regulation. None appear to be necessary or sufficient to cause depression, nor are there known factors that offer complete protection from depression.

There appears to be a substantial genetic component in the more severe forms of depression, such as bipolar disorders and major depression. How this genetic influence is manifested physiologically is not yet known. Several biological abnormalities have been identified in subgroups of individuals exhibiting depression. However, most of them appear to occur during a depressed episode and to subside once a normal mood state is attained. None appear to be universally shared by clinically depressed individuals. Developmental influences also appear to be risk factors for depression, such as being born to a mother who is currently depressed, the loss of parents in childhood, and a high number of stressful life events. Social and environmental factors also have well-documented effects on depression. For example, poverty has been shown to account for approximately 10% of new cases of major depression.

The emotion regulation literature suggests that certain mechanisms can be used to affect whether a given emotion occurs or to modulate the intensity, duration, and tone of the emotion once it has been triggered. Factors that can come into play prior to the triggering of the emotion include changes in either the external or the internal environment, that is, either in the environment in which the individual is located (including the people in such an environment) or in the mind of the individual. Attention, memory, mental rehearsal, and the interpretation of the material brought into consciousness via these avenues, all can set the probabilities of certain emotions being triggered. Once an emotion is triggered, the responses of the individual to the emotion can maintain or diminish the intensity and duration of the emotion.

Developmental aspects of emotion regulation include the basic survival aspects of emotion expression in infants, including the instrumental functions of crying or smiling, cooing, and vocalizing; the development of language and its role in modulating emotional response when used by others and by the child; the differential reinforcement and punishment of specific emotions; acquiring expectations regardingwhich kinds of emotion regulation are possible by observing role models; and, as the individual moves into adolescence and adulthood, gaining greater ability to shape one’s environment, choosing one’s friends, activities, and school and work settings. Certain professional training includes fairly specific instructions regarding the types of emotional expression that are preferred, discouraged, or prohibited.

The development of healthy mood management or emotion regulation is a key prerequisite of mental health. As individuals develop, a large proportion attempt to modulate their mood by maladaptive methods, including the use of psychoactive substances. If these methods become part of the person’s usual repertoire, they can have serious long-term consequences. The delineation of mood management strategies and their consequences deserves further study and dissemination.

Mood management skills are important in at least three broad contexts: work, relationships, and aloneness. The ability to maintain a healthy mood state in each of these situations appears to be necessary to good mental health. The theoretical factors that have been important in the development of treatment modalities can be integrated into a concept of mood management. Each addresses a different level of analysis: biological approaches focus on the neurochemical bases of emotion regulation, cognitive–behavioral approaches focus on psychological mediators of emotion regulation, and interpersonal approaches emphasize the influences of interpersonal relations on emotion regulation and dysregulation.

VII. Conclusion

Depression is an experience that has been shared by most human beings at one time or another. Thus, it can be thought of as a feeling state that is within the realm of normal functioning. If the frequency, intensity, and duration of this feeling increase, it can become a pathological process. After it crosses a certain threshold, criteria for which are now well-defined, it is diagnosed as a specific mental disorder. Mental health interventions that focus on this disorder include preventive, treatment, and maintenance interventions, of which treatment is the most developed and the most available. The public health impact of depression is considerable. Advances in the identification and dissemination of effective mood management strategies could have a major impact in the health of our societies.

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