Major depression is the most common chronic condition facing the primary care physician today.

PSYCHOLOGY ASSIGNMENT.

Depression.

Introduction.

Major depression is the most common chronic condition facing the primary care physician today. Of all patients visiting their doctor, 5-9% suffer from this disorder. The prevalence of major depression has increased since the 1950s in all age groups and psychiatrists have for many years debated whether this condition is caused by biological or behavioural factors. The debate has been between the use of drugs or therapies to combat this disorder. This debate has been misguided in so far as many diseases have both a biological and behavioural cause, including major depression. Paul A Kettl, MD Major depression, the forgotten illness.

The characteristic features of depression are feeling low, lethargy, and negative thought processes; sleep disorders and loss of appetite. Depression is more intense and sustained than ordinary sadness and involves feelings of ‘worthlessness, guilt and pessimism.

‘Unipolar depression’ can occur at any age and may appear gradually or suddenly.

In Britain around fifty percent of adults between eighteen and seventy-four will experience serious depression. The number of people seeking help from their GPs for depression was nine million in 1998, (Bps 1999).

Bipolar disorder (Mania), generally appears in the early twenties, unlike depression (which is more common in women), Cochrane (1995), bipolar disorder is equal in both men and women, although it is less common than depression. Interestingly there is a disproportionately higher incidence of bipolar disorder among creative people Jamison (1989). For example of forty-seven award winning British writers and artists thirty eight percent were treated for the disorder, the figure in the general population is about one percent.

Genetic factors play a major role in the probability of some people experiencing depression occurring in about one in every hundred people. These genetic traits are not always detrimental to the person, as in some cases the incidence of bipolar disorder can be advantageous to some creative people, Jamison, (1989). The connection between anxiety and depression is almost one hundred percent, Kendler et, al, (1992), which suggests the genes responsible for anxiety are almost certainly responsible for depression also. In general it seems that anxiety results from anticipation of loss whereas depression is a result of loss Hamer and Copeland, (1999). William Scheftner, MD, medical director for research at the (Rush Institute for Mental Well-Being), states that.

‘Inherited depressions are transmitted by genetic material or DNA, which is present at the moment of birth. These genes are located on chromosomes, what isn’t clear is which gene or how many genes are involved. This study is designed to be the first of many steps in identifying the locations of the genes for unipolar major depressive disorder. Once they are located, we can then begin to develop tests that will provide earlier diagnosis and determine how the genes biochemically cause depression’.

The neurotransmitter serotonin appears to play a significant role in depressive disorders. Studies of Vervet monkeys found that the alpha male in the group had levels of serotonin twice as high as lower males in the group, Raleigh, McGuire (1991). When the alpha male lost the position of head of the group the serotonin levels dropped significantly and they showed signs of depression. Anti depressant drugs such as Fluoxetine, (Prozac), can reverse the loss of serotonin and when administered to a random male that male became the new alpha male of the group. This research suggests that serotonin plays ...

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Some evidence suggests that we may be in an epidemic of depression. Ness and Williams, (1996), examined thirty nine thousand people in five different parts of the world and found that young people have far more episodes of depression than their elders, furthermore, depression is more common in societies with greater degrees of economic development. Reasons cited for this phenomena is worries about environmental change, economic uncertainty and increasing hierarchical competition. The development of mass communication means that we now compete on the world stage and against the best in the world. All these factors are potential triggers for a depressive episode.

An optimistic or pessimistic view of modern society can also play a major role in the onset of depressive disorder. Behavioural explanations focus on the role played by reinforcement, Ferster, (1995). Lewinshon, (1974), argues that the social inactivity of people with depression leads to a concerned attention from loved ones and friends which reinforces the depressed behaviour, after care and attention wane this exacerbates the depression in a cyclic degeneration. Lewinshon also points to positive reinforcement as part of a healthy interactive need in people. Depressed people report having fewer pleasant experiences than non- depressed people. Fewer pleasant reinforcing experiences implies that people who become depressed lower their participation in positive reinforcement.

A link between behavioural and cognitive perspectives was suggested by Seligman (1975-1992), Seligman & Maier, (1967) found in their research using dogs who were restrained and unable to avoid electric shocks, appeared to become passive and resigned to the shocks. Later when free to move and avoid the shocks, the dogs made no attempt to do so. Seligman termed this as ‘learned helplessness’ this was criticised because it did not take into account that some depressed people blame themselves for their depression whilst others blamed the external world for their depression. A refined version of learned helplessness theory suggests the attributions and interpretations that people put on their experiences are reflected in the way people either blamed the external world or themselves for their depression, Abramson, et al. (1978). According to Abramson et al, people who look at failure as their fault with no way up so to speak are more likely to become depressed. The negative attribution to their plight reinforces their feelings of helplessness. This attributional style derives from learned histories such as family and school. According to questionnaires that looked at the way people interpret adversities in their life, to some degree, were able to predict the future susceptibility to depression of those who took part, Kinderman & Bentall, (1997). However once a depressive episode ends the cognititions of helplessness ends also. Gotlib & Colby, (1995), suggest that an attitude of helplessness could be a symptom rather than a cause for depression, they found that there is no difference between people who where formerly depressed and people who have never been depressed, when it came to viewing negative events with a helpless resignation.

Overall the capacity of people to experience sadness & joy is probably related to the punishment reward system within the realm of reproductive success. Unipolar and bipolar disorders are the extremes of this system. There are a number of reasons to associate the capacity for sadness as an adaptive trait elicited by certain cues, specifically by a loss of reproductive resources, such as money, a mate, health or relatives. Loss in this context signals adaptive behaviour, where future losses are prevented. Two aspects of sadness might increase fitness, on the one hand it may motivate us to cease activities that may be causing losses and on the other hand it may prevent the usual tendency of optimism and enable us to assess our lives more effectively. Studies have found that most of us tend to overestimate our abilities and effectiveness. This is normally adaptive; it enables us to succeed in social competition and keeps us pursuing important strategies and relationships even at times when there is no pay off. Psychology a new introduction, Richard Gross et al. (2000).

Similarly, a manic reaction may be triggered by the perception of a gain in reproductive resources or (resource holding power, RHP). Gilbert (1990), describes this as a gain in ‘social attention-holding potential, (SHAP). SHAP refers to the quality of attention others pay to a particular person. According to Gilbert, humans compete with each other to be attended to, and valued by those in the group. When a group bestows a lot of quality attention toward an individual that individual rises in status. Ignored individuals are banished to low status. Extreme rises or falls in status may lead to mania or depression respectively. Attachment theory, Groes et al, (2000), is a possible explanation of affective disorders. According to Stevens & Price (1996).

‘ The foundation of a warm, intimate and lasting relationship with a dependable attachment figure is the basis of human happiness and security’.

Threats to this relationship can cause anxiety and loss of an attachment figure may result in depression.

Depression as a pathological state is particularly likely to occur in people who, because of ineffective attachment in childhood, fail to develop a mature capacity to deal with loss. Studies show that people prone to depression recall a lack of parental affection Parker (1984). A problem with this theory is that it does not recognise the capacity of people to transcend childhood trauma.

The different theories relating to Unipolar and Bipolar disorders, excluding genetic and biochemical reasons for depression, point to the individuals ability in giving and accepting affection as part of the probabilities of whether or not the likelihood of a depressive episode will occur. These abilities are learned, or not learned in childhood. An optimistic or pessimistic attitude to life goes a long way in how the individual perceives and interprets the world around them.

Treatments for depression are becoming more effective as new drugs and therapies are discovered, the emphasis on cognitive therapies is encouraging in so far as it enables the person to better manage episodes of depressive disorders. Many forms of psychotherapy, including some short-term (10-20 week) therapies, can help depressed individuals. ‘Talking therapies help people gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with homework assignments between sessions. Behavioural therapists help people learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioural patterns that contribute to or are part of their depression.

Two short term psychotherapies that research has shown helpful for some forms of depression are interpersonal and cognitive/behavioural therapies. Interpersonal therapists focus on the person’s disturbed personal relationships that both cause and exacerbate the depression. Cognitive/behavioural therapists help people change the negative styles of thinking and behaving often associated with depression.

Psychodynamic therapies, which are sometimes used to treat depressed people, focus on resolving the persons conflicted feelings. These therapies are often reserved until the depressive symptoms are significantly improved.

In general, severe depressive illnesses, particularly those that are recurrent, will require medication and today there are new drugs with less side affects than those, which have been used in the past. Most doctors today use the SSRIs, (Selective Serotonin Reuptake inhibitors). Introduced about a decade ago, these SSRIs have proven to be safe and affective with fewer adverse side effects than earlier drugs such as the tricyclic anti-depressants. The four current SSRIs are Fluoxetine, sertraline, paroxetine and citalopram.

Electro-convulsive Therapy is one of the most successful but controversial treatments for major depressive disorder. This treatment has been portrayed in films as cruel, barbaric, inhumane and almost torture like in the way it has been used in the care of people with depression. However it still remains one of the most effective treatments for major depression. Simply it works by disrupting the long-term memory through he introduction of short bursts of electricity to the person’s brain, creating in effect a ‘seizure’ or resetting the brain to its factory setting.

In conclusion, the research for this essay suggests that there is a bright future for people who suffer this debilitating disorder. Innovation in humanistic therapies and the use of effective drugs are beginning to win the battle in helping people with this disorder. The world and the problems facing us all in the future are serious enough to make anyone depressed at some time or other. It will continue to effect people of all ages and cultures until such time as we can resolve some of the more destructive elements in our make up as human beings.