What is depression?
Depression has a variety of symptoms, such as loss of energy, loss of interest in activities and in life, sadness, loss of appetite and weight, difficulty concentrating, self-criticism, feelings of hopelessness, physical complaints, withdrawal from other people, irritability, difficulty making decisions, and suicidal thinking. Most depressed people feel anxious as well. They often feel worried, nauseated, dizzy, and sometimes have hot and cold flashes, blurred vision, racing heartbeat, and sweating.
Clinical depression is not the same as grieving after the loss of a loved one through death, separation or divorce. Feelings of sadness, emptiness, low energy and lack of interest are normal during grief. Anger and anxiety can also be part of the normal grief process. Many women may suffer from post-partum depression—but also suffer from anxiety and depression before the birth of their child.
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Clinical depression differs from normal grief in that clinical depression sometimes may occur without a significant loss. Moreover, depression may last longer than grief and includes feelings of self-criticism, hopelessness and despair.
It would be an unusual person who said that he never felt “depressed.” Mood fluctuations are normal and help inform us that something is missing in our lives and that we should consider changing things. But clinical depression is much worse than simple fluctuations in mood. Clinical depression varies from mild to severe. For example, some people complain of a few symptoms which occur some of the time. Other people, suffering from a severe depression, may complain of a large number of symptoms, which are frequent, long-lasting and quite disturbing. Because there are various degrees of depression, the severely depressed patient may wish to consider a number of treatments in combination.
Who Gets Depressed?
Depression is not something that happens to people who are “unusual” or “crazy.” It is everywhere. Along with anxiety (which occurs more frequently than depression), it is the common cold of emotional problems. During any given year a large number of people will suffer from a major depression. 25% of women and 12% of men will suffer a major depressive episode during their lifetime. The chances of reoccurrence of another episode after the initial episode are high.
The reason for the sex difference in prevalence of depression is not entirely clear. Possible reasons may be that women are more willing to acknowledge feelings of sadness and self-criticism, females are undermined from an early age by being taught to be helpless and dependent, women control fewer sources of rewards than men do, and their achievement is often discounted. Another factor may be that men “mask” or hide their depression behind other problems, such as alcohol and drug abuse.
Depression can affect all areas of your life. 80 percent of people who are currently depressed say that they are impaired in their daily functioning. One study found that people with major depression lost 5.6 hours of productive work per week. Depression often occurs with other problems that add to the difficulty of overcoming the depression. 75% of people with depression suffer from another psychological problem of which 59 % have anxiety disorders and 24% have substance abuse disorders. Depressed individuals are five times more likely to abuse drugs. Women with marital conflicts are 25 times more likely to be depressed than women without conflicts. Depressed people have higher rates of cardiovascular disease and other medical problems and are more likely to have “unhealthy” life-styles (smoking, overeating, not exercising, and other problematic behaviors). The cost of depression in terms of lost productivity or increased utilization of medical services is estimated to be over 82 billion dollars.
What Are The Causes Of Depression?
There is no “one” cause of depression. We view depression as “multi-determined” – that is, it has biochemical, behavioral and cognitive components. We will examine each one.
- Loss of Rewards. Have you experienced significant losses in your life recently – for example, loss of work, friendships, intimacy? The behavioral model of depression emphasizes the importance of reinforcement in the onset and maintenance of depression. There is considerable research evidence that people who suffer significant life stresses are more likely to become depressed – especially, if they lack or do not use appropriate coping skills.
- Decrease of Rewarding Behavior. Are you engaged in fewer activities which were rewarding in the past? Depression is characterized by inactivity and withdrawal. For example, depressed people report spending a lot of time in passive and unrewarding behavior – such as watching television, lying in bed, brooding over problems and complaining to friends. They spend less time engaged in challenging and rewarding behavior, such as positive social interactions, exercise, recreation, learning, and productive work.
- Skill Deficits. Are there social skills or problem – solving skills which you lack? Depressed people may have difficulty asserting themselves, maintaining friendships, or solving problems with their spouses, friends, or work colleagues. Because they either lack these skills or do not use the skills they have, they have greater interpersonal conflict and fewer opportunities to make rewarding things happen for them.
- New Demands.: Are there new demands for which you feel ill-prepared? Moving to a new city, starting a new job, becoming a parent, or ending a relationship and trying to find new friends can be sources of significant stress for many people.
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- Lack of self-reward. Many depressed people fail to reinforce themselves for positive behavior. For example, they seldom praise themselves or they are hesitant to spend money on themselves. Many times depressed people think that they are so unworthy that they should never praise themselves. Some depressed people think that if they praise themselves that they will become lazy and settle for less.
- Exposure to helplessness.: Depression may result from continuing to stay in a situation in which you cannot control rewards and punishments. The individual may feel sad, tired, loss of interest, and hopeless because he believes that no matter what he does he cannot make things better. Examples of helplessness are unrewarding jobs or dead-end relationships.
- Exposure to continual punishment. This is a special kind of helplessness – not only are you unable to get rewards, but you find yourself criticized by others and rejected. For example, many depressed people may spend time with people who criticize them or hurt them in various ways.
Although each of the above factors may make you prone to depression, they do not necessarily have to result in depression. One may experience a loss in life but reverse the loss by increasing rewarding behaviors, learning new skills, redirecting attention and energy into new goals, and asserting yourself. You are also more likely to become depressed if you think that you are entirely to blame, that nothing can change and that you should be perfect at everything. These interpretations of stress and loss are the “cognitions” or thoughts that you have about yourself and your environment. Cognitive therapy is specifically focused at identifying, testing, challenging and changing these excessively negative views of life. Let’s take a closer look at how you might be thinking.
How Does Thinking Affect Depression?
There are other causes of depression that have to do with the way you think (your “cognitions”). Some of these causes of depression are described below:
- Unrealistic expectations. Many depressed people have unrealistically high standards for themselves and for other people. They believe that they (or others) shouldn’t make mistakes, their job should be free of conflict or should be fun all the time, or that their marriage should be completely happy. Another group of depressed people have unrealistically low standards – they continually accept less than they could probably get elsewhere.
- Automatic thoughts. These are thoughts that come spontaneously, seem plausible, and are associated with negative feelings like sadness, anxiety, anger and hopelessness. Examples of these distortions in thinking are the following:
- Mind reading “He thinks I’m a loser”
- Labeling “I’m a failure. He’s a jerk.”
- Fortune telling “I’ll get rejected. I’ll make a fool of myself.”
- Catastrophizing “It’s awful if I get rejected. I can’t stand being anxious.”
- All or nothing “I fail at everything. I don’t enjoy anything. Nothing works out for me.”
- Discounting positives “That doesn’t count because anyone could do that.”
- Maladaptive assumptions. These are the rules or philosophies of depressed people. They include ideas about what you think you should be doing or your theories about life:
- “I should get the approval of everyone.”
- “If someone doesn’t like me, that means I’m unlovable.”
- “I can never be happy doing things on my own.”
- “If I fail at something, then I’m a failure.”
- “I should criticize myself for my failures.”
- “If I’ve had a problem for a long time, then I can’t change.”
- “I shouldn’t be depressed.”
- Negative self-concept. People who are depressed often focus on their short-comings, exaggerate them, and minimize any positive qualities they may have. They may see themselves as unlovable, ugly, stupid, weak, or even evil.
Are there styles of thinking that make you more depressed?
- Rumination. Depressed people are more likely to ruminate about negative things—that is, they go over unpleasant thoughts and experiences —over and over. Typical ruminations are, “Why is this happening to me?, “I feel so bad I can’t stand it”, or “I need to figure out why things are the way they are.” These endless repetitive negative self-preoccupations keep you stuck in a negative rut of thinking and feeling. Moreover, while you are ruminating you are not actively solving problems and not experiencing rewarding things in the real world.
- Negative explanatory style. Another aspect of depression is called “negative explanatory style”. For example, if something bad happens you are more likely to blame yourself, think that your negative qualities will never change and then generalize it to other things in your life. You might not do well on an exam and then conclude, “I must be stupid, I can’t do anything, and I may as well give up”. Non-depressed people are more likely to think that not doing well might be due to not putting in as much effort or that this particular task was too hard—but that they can do well on other things.
- Vague and overgeneral memory. Depressed people often have vague recollections of events—what we call “overgeneralized memory”. Rather than think, “I felt frustrated because John didn’t help out with the kids last night” (a specific memory), a depressed person might think, “Life is really bad and I can’t seem to get any support”. This overgeneralized and vague memory makes it hard to solve problems because you can’t pin down precisely what you need to do.
- Emotion focus rather than problem focus. Depressed people focus more on how they feel rather than what they can do to solve a problem. Although feelings are very important in therapy, learning how to evaluate situations accurately and engage in active problem solving can help empower you to overcome difficulties.
- Losses in relationships. Sometimes depression follows a breakup or loss of a relationship. Divorce or separation, losses of friendships, and even moving to a new place where you no longer have contact with people can make you more vulnerable. Coping with loss, loneliness, regrets, resentments and other problems following loss can help you overcome your depression.
- Conflicts in relationships. Frequent arguments, unresolved issues, lack of reward and feeling uncared for all add to your risk of depression. Cognitive therapy can help you and your partner learn effective ways of acting toward each other and communicating more productively. Learning to show kindness, compassion, forgiveness, and learning how to solve problems mutually can go a long way to helping you resolve conflicts.
- Problematic coping styles. It may be that you or your partner—or both of you—have problematic or unhelpful ways of dealing with issues. This includes labeling your partner, withdrawing, contemptuous statements, passivity, and complaining. You and your therapist can identify these problematic styles and develop a plan to use more effective means of coping.
- Lack of empathy or validation. We all need to feel cared for and understood. Frequently, people who are depressed find that they can’t get the emotional support and warmth in their relationships. You and your partner—and others—can learn how to ask for support in ways that can lead to active, effective empathic listening. It’s important to feel that your emotions are cared for.
What Is Cognitive-behavioral Treatment?
The cognitive-behavioral treatment of depression is a highly structured, practical, and effective intervention for patients suffering from depression. In cognitive-behavioral therapy the therapist initially attempts to focus on current symptoms and current thoughts and behaviors. The therapist and patient evaluate the specific level of depressive and anxiety symptoms using standardized, valid self-report forms that assess your relationships, personality style, worry, emotional coping, decision-making and other issues. The effectiveness of the therapy may be monitored by referring to these initial measures of symptoms and other goals which the patient establishes with the therapist. For example, the patient is asked in the initial meetings to specify a number of goals he wishes to attain – such as, increasing self-esteem, improving communication, reducing shyness, or decreasing hopelessness and loneliness.
How Effective Is Cognitive-behavior Therapy for Depression?
Numerous outcome studies conducted at major universities throughout the world have consistently demonstrated that cognitive therapy is as effective as anti-depressant medication in the treatment of major depression. Within 20 sessions of individual therapy, approximately 75% of patients experience a significant decrease in their symptoms. The combination of cognitive therapy with medication, in some studies, increases the efficacy to 85%. Individual responses will vary. Moreover, most patients in cognitive therapy maintain their improved mood on follow-up two years later. This advantage of “maintaining gains” is due to the fact that in cognitive therapy the patient should not only reduce his symptoms, but he should learn to understand the distortions in thinking and behavior which are associated with the depression and learn self-help rather than dependence.
Are Medications Useful?
There are a variety of medications that are quite effective in the treatment of depression. There are various classes of anti-depressant medications—and your doctor may find that combining medications for more than one class can help you. A recent national multisite study on depression found that switching and adding to different classes of medications eventually led to a significant increase in the per cent of patients who improved. The most common classes of medications are the following: SSRIs — which include Prozac, Zoloft, Paxil, Luvox, Celexa, and Lexapro; (MAOI), such as Nardil or Parnate; Tricyclic antidepressants (TCAs), an older class of medication, which includes doxepin, Clomipramine, Nortriptyline, Amitriptyline, Desipramine, and Trimipramine. Other anti-depressants include Trazondone (Desyrel) and nefazadone (Serzone), Buproprion (Wellbutrin), venlafaxine (Effexor), milnacipram and duloxetine; Norepinephrine (noradrenaline) and reboxetine (Edronax). You can also consider mirtazapine (Avanza, Zispin, Remeron). Your doctor may augment your anti-depressant medications with amphetamine substances such as Adderall and Ritalin to increase your energy level. Tryptophan can be used to augment treatment, although one should be cautioned about possible side effects of this drug. In some cases, your doctor may prescribe a low dosage of an anti-psychotic to reduce the rigidity of your negative thinking. Antipsychotics include quetiapine (Seroquel), risperidone (Risperdal), and olanzapine (Zyprexa). Usually they are prescribed for a shorter period of time, just until your depression has lessened somewhat.
It takes two to four weeks (or longer) for you to build up a therapeutic level. Some medications may have negative side effects and some of these side effects may decrease over time or they may be handled with combinations of other medications. In some cases, patients with severe depression may wish to consult their physician about the possibility of electro convulsive treatment (ECT).
What We Expect from You as a Patient
Cognitive-behavioral treatment of depression requires your active participation. During the initial phase of therapy your therapist may request that you come to therapy twice per week until your depression has decreased. You will be asked to fill out forms evaluating your depression, anxiety and other problems, and to read materials specifically addressing the treatment of depression. In addition, your therapist may ask you to fill out forms weekly that evaluate your depression and other problems that are the focus of therapy. Your therapist may give you homework exercises to assist you in modifying your behavior, your thoughts, and your relationships. Although many patients suffering from depression feel hopeless about improvement, there is an excellent chance that your depression may be substantially reduced with effective treatment.
Seasonal Affective Disorder (SAD)
One variation of depression is known as “Seasonal Affective Disorder” (SAD) which is characterized by greater likelihood of depressive symptoms in the winter months (a small minority of patients have a reverse seasonal component with worse mood, often with anxiety, during the summer). People with SAD have worse mood in the morning, low energy, increased appetite (especially for carbohydrates), increased weight gain, lower activity, and greater withdrawal and passivity. You can think of this as a “hibernation” response, since it mimics some of the same qualities of hibenation in animals residing in very cold climates. The evolutionary advantage of SAD is that it lowers metabolism, stores calories for a long winter of deprivation, decreases procreation during the winter when it would be least likely to succeed, and reduces activity level which would generally be pointless. The sensitivity to light–with increased SAD with increased hours of darkness– supports this evolutionary interpretation. The likely physiological factor underlying SAD is decreased serotonin.
Increasing exposure to light can improve SAD for many people. This can be accomplished through light-box treatments (mentioned below) or by getting out in the morning and taking a thirty minute walk in the daylight without wearing sunglasses. Anti-depressant medication is also helpful, some people benefit from melatonin, and others benefit from cognitive-behavioral therapy, especially with an emphasis on increasing behavior and increasing social contacts.
Up to 38% of patients seeking treatment for depression have a seasonal component to their disorder and 5% of the general public has SAD. Women are more likely than men to suffer from SAD.Light therapy (LT) is often prescribed for patients with SAD and research indicates that it can be quite effective. In fact, recent research shows that combined cognitive therapy with light therapy for SAD is the most effective treatment.
Bright light (Light Therapy) helps wake you up in the morning and jump-start your circadian rhythms. You can get bright light for 15 to 30 minutes from sunlight, a high intensity lamp, or by purchasing a commercially produced bright light specifically designed for this purpose. Commercially available bright lights are available from Apollo Light (www.ApolloLight.com,) or Sunbox (www.Sunbox.com) and other manufacturers. Some patients with SAD also benefit from melatonin supplements. Finally, negative air ionization can also be effective in reducing SAD. (From Robert L. Leahy, Beat the Blues Before They Beat You: Overcoming Depression).
For more information on depression and other problems see:
- Beat the Blues Before They Beat You: Overcoming Depression
-Robert L. Leahy
Read the First Chapter of Beat the Blues Here
- The Development of Psychopathology: Nature and Nurture
-Bruce F. Pennington
- Handbook of Depression: 2002 Edition
-Edited by Ian H. Gotlib and Constance L. Hammen
- Overcoming Resistance in Cognitive Therapy
-Robert L. Leahy
- Cognitive-Behavior Therapy for Mood Disorders
-Willem Kuyken, Ed Watkins, and Aaron T. Beck
- National Institute for Health and Clinical Excellence (UK): Depression
For more information on recommendations and best practices for reporting on suicide:
- The American Association of Suicidology’s (AAS) recommendations
- The National Action Alliance for Suicide Prevention’s recommendations
Blog Posts on Depression:
- Dr. Scott Woodruff on coping with SAD on The Weather Channel
Sample Chapters from Guilford Press
- Adapting Cognitive Therapy for Depression: Managing Complexity and Comorbidity Edited by Mark A. Whisman
- Behavioral Activation for Depression: A Clinician’s Guide by Christopher R. Martell, Sona Dimidjian, and Ruth Herman-Dunn
- Breaking Free from Depression: Pathways to Wellness by Jesse H. Wright and Laura W. McCray
- CBT for Depression in Children and Adolescents by Betsy D. Kennard, Jennifer L. Hughes, and Aleksandra A. Foxwell
- CBT Strategies for Anxious and Depressed Children and Adolescents by Eduardo L. Bunge, Javier Mandil, Andres J. Consoli, and Martin Gomar
- Depression in Adolescent Girls: Science and Prevention Edited by Timothy J. Strauman by Philip R. Costanzo, and Judy Garber
- Geriatric Depression by Gary J. Kennedy
- Handbook of Depression in Children and Adolescents Edited by John R. Z. Abela and Benjamin L. Hankin
- Handbook of Depression, Second Edition by Ian H. Gotlib and Constance L. Hammen
- Interpersonal Psychotherapy for Depressed Adolescents, Second Edition by Laura Mufson, Kristen Pollack Dorta, Donna Moreau, and Myrna M. Weissman
- Metacognitive Therapy for Anxiety and Depression by Adrian Wells
- The Mindful Way through Depression: Freeing Yourself from Chronic Unhappiness by Mark Williams, John Teasdale, Zindel Segal, and Jon Kabat-Zinn
- Skills Training Manual for Diagnosing and Treating Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy by James P. McCullough, Jr.
- Treating Depressed and Suicidal Adolescents: A Clinician’s Guide by David A. Brent, Kimberly D. Poling, and Tina R. Goldstein
- Treatment Plans and Interventions for Depression and Anxiety Disorders, Second Edition by Robert L. Leahy, Stephen J.F. Holland, and Lata K. McGinn
- Vulnerability to Depression: From Cognitive Neuroscience to Prevention and Treatment by Rick E. Ingram, Ruth Ann Atchley, and Zindel V. Segal
- Winter Blues, Revised Edition: Everything You Need to Know to Beat Seasonal Affective Disorder by Norman E. Rosenthal
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