Introduction (Psychology and Mental Health)
Almost everyone gets “down in the dumps” or has “the blues” sometimes. Feeling sad or dejected is clearly a normal part of the spectrum of human emotion. This situation is so common that a very important issue is how to separate a normal “blue” or “down” mood or emotion from an abnormal clinical state. Most clinicians use measures of intensity, severity, and duration of these emotions to separate the almost unavoidable human experience of sadness and dejection from clinical depression.
Depression is seen in all social classes, races, and ethnic groups. It is so pervasive that it has been called “the common cold of mental illness” in the popular press. It is approximately twice as common among women as it is among men. Depression is seen among all occupations, but it is most common among people in the arts and humanities. Famous individuals such as U.S. president Abraham Lincoln and British prime minister Winston Churchill had to cope with depression; Churchill called the affliction “the black dog.” Beach Boy Brian Wilson, journalist Mike Wallace, actors Owen Wilson and Brooke Shields, and musicians Kurt Cobain and James Taylor were known to have bouts of serious depression.
Of all problems that are mentioned by patients at psychological and psychiatric clinics, some form of depression is most common. It is estimated that approximately 25 percent of women in the United States will experience at...
(The entire section is 684 words.)
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Cognitive and Stress Theories (Psychology and Mental Health)
A different approach to understanding depression has been put forward by cognitive theorists. According to Aaron T. Beck, in Cognitive Therapy and the Emotional Disorders (1979), cognitive distortions cause many if not most of a person’s depressed states. Three of the most important cognitive distortions are arbitrary inference, overgeneralization, and magnification and minimization. Arbitrary inference refers to the process of drawing a conclusion from a situation, event, or experience when there is no evidence to support the conclusion or when the conclusion is contrary to the evidence. For example, an individual concludes that his boss hates him because he seldom says positive things to him. Overgeneralization refers to an individual’s pattern of drawing conclusions about his or her ability, performance, or worth based on a single incident. An example of overgeneralization is an individual concluding that she is worthless because she is unable to find her way to a particular address (even though she has numerous other exemplary skills). Magnification and minimization refer to errors in evaluation that are so gross as to constitute distortions. Magnification refers to the exaggeration of negative events; minimization refers to the underemphasis of positive events.
According to Beck, there are three important aspects of these distortions or depressive cognitions. First, they are automatic—that...
(The entire section is 753 words.)
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Treatment Methods (Psychology and Mental Health)
There are a number of ways to understand depression, and each approach appears to have something to offer. Given the distressing nature of depression, it is not surprising that these differing approaches have led in turn to several effective ways of treating depression.
Pharmacological interventions for unipolar depression have sometimes been held to normalize a genetically determined biochemical defect; the evidence, however, does not support this extreme biological characterization of unipolar depression. Yet neurotransmitters may directly mediate many of the behaviors affected in depression (for example, sleep, appetite, and pleasure), and neurotransmitter level and activity are disturbed as a concomitant of many episodes of depression. Hence, the use of antidepressant agents that influence neurotransmitter level or activity should be helpful in reducing or eliminating symptoms of depression even if the disturbance in neurotransmitter level or activity is itself the result of environmental or cognitive changes. In addition, there is considerable direct evidence that antidepressants can be useful in the treatment of depression in many cases. In controlled trials, both more recently developed and older forms of antidepressants provided improvement rates of 66 to 75 percent, in contrast to placebos, which showed improvement rates of 30 to 60 percent. Exactly for whom they will work, however, and exactly how or why they work...
(The entire section is 458 words.)
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From Melancholy to Prozac (Psychology and Mental Health)
The identification of depression as a recognizable state has a very long history. Clinical depression was described as early as the eighth century b.c.e. in the biblical descriptions of Saul. During the fourth century b.c.e., Hippocrates coined the term “melancholy” to describe one of the three forms of mental illness he recognized. Later, Galen attempted to provide a biochemical explanation of melancholy based on the theory of “humors.” Indeed, repeated descriptions and discussions of depression are present from classical times through the Middle Ages and into modern times.
The first comprehensive treatment of depression in English was provided by Timothy Bright’s Treatise of Melancholia (1586). In 1621 Robert Burton provided his own major work on depression, The Anatomy of Melancholy. Most of the credit for developing the modern understanding of affective disorders, however, is given to Emil Kraepelin, a German psychiatrist. It was in Kraepelin’s system that the term “depression” first assumed importance.
Since classical times, there has been debate about whether depression is best considered an illness or a response to an unhappy situation. Indeed, it is obvious to the most casual observer that sadness is a normal response to unhappy events. Even now, there is less than complete agreement on when fluctuations in mood should be considered pathological and when they are...
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Sources for Further Study (Psychology and Mental Health)
Beach, Stephen R. H., E. E. Sandeen, and K. D. O’Leary. Depression in Marriage. New York: Guilford, 1990. Summarizes the literature on basic models of depression. Provides the basis for understanding the important role of marriage in the etiology, maintenance, and treatment of depression.
Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. 1976. Reprint. London: Penguin, 1991. Clearly lays out the basics of the cognitive model of depression. An important start for those who wish to understand the cognitive approach more thoroughly.
Burns, David D. Feeling Good: The New Mood Therapy. Rev. ed. New York: William Morrow, 2002. Provides a very entertaining and accessible presentation of the cognitive approach to depression. Presents basic results and the basics of cognitive theory, as well as a practical set of suggestions for getting out of a depression.
Coyne, James C., ed. Essential Papers on Depression. New York: New York University Press, 1985. Includes representatives of every major theoretical position advanced between 1900 and 1985. Each selection is a classic presentation of an important perspective. This source will acquaint the reader with the opinions of major theorists in their own words.
Coyne, James C., and G. Downey. “Social Factors and Psychopathology: Stress, Social Support, and Coping Processes.” Annual Review of...
(The entire section is 486 words.)
Depression (Salem Health: Cancer)
Risk factors: Depression is most common among cancer patients with advanced disease and with symptoms and discomfort that are not treated or inadequately treated. It commonly coexists with anxiety and is common in individuals with substance abuse problems and other chronic physical and mental disorders. Most cancer patients manifest transient symptoms of depression that are responsive to support, reassurance, and information about what to expect regarding the course, treatment, and prognosis of their disease. Others experience unremitting or recurrent depression requiring aggressive monitoring and intervention. The following list depicts risk factors that favor the development of clinically significant depression within the context of a cancer diagnosis:
- Family history of depression
- Past history of depression, depression treatment, psychiatric hospitalization, or significant psychiatric/personality disorder
- History of unusual, eccentric behavior
- Confusion (may be indicative of an organically based depression)
- Maladaptive coping style
- Dysfunctional family coping or complex family issues
- Limited social support
- Financial problems including lack of insurance
- Multiple roles, obligations, and stressors
- Advanced cancer
- Treatment resulting in disfigurement or loss of function
- Presence of dependent children
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For Further Information (Salem Health: Cancer)
Akechi, Tatsuo, et al. “Major Depression, Adjustment Disorders, and Post-traumatic Stress Disorder in Terminally Ill Cancer Patients: Associated and Predictive Factors.” Journal of Clinical Oncology 22, no. 10 (May 15, 2004): 1957-1965.
Carr, D., et al. Management of Cancer Symptoms: Pain, Depression, and Fatigue. Evidence Report/Technology Assessment 61. AHRQ Publication No. 02-E032. Rockville, Md.: Agency for Healthcare Research and Quality, 2002.
Fleishman, S. “Treatment of Symptom Clusters: Pain, Depression, and Fatigue.” Journal of the National Cancer Institute: Monographs 2004, no. 32 (2004): 119-123.
Lloyd-Williams M. “Screening for Depression in Palliative Care Patients: A Review.” European Journal of Cancer Care 10 (2001): 31ff.
Parker, P. A., W. F. Baile, C. de Moor, and L. Cohen. “Psychosocial and Demographic Predictors of Quality of Life in a Large Sample of Cancer Patients.” Psychooncology 12, no. 2 (2003): 183-193.
Patrick, D. L., et al. “National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002.” Journal of the National Cancer Institute 95 (2003): 1110ff.
(The entire section is 151 words.)
Other Resources (Salem Health: Cancer)
Abramson Cancer Center of the University of Pennsylvania. Oncolink. http://www.oncolink.org/resources
American Psychosocial Oncology Society. http://www.apos-society.org
Cancer Care. http://www.cancercare.org
National Institute of Mental Health. Depression. http://www.nimh.nih.gov/health/topics/depression/index.shtml
Substance Abuse and Mental Health Services Administration. http://www.samhsa.gov
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Risk Factors (Genetics & Inherited Conditions)
Females and the elderly are at risk for depression. Other risk factors include chronic physical or mental illness, including thyroid disease, headaches, chronic pain, and stroke; a previous episode of depression; major life changes or stressful life events, such as bereavement or trauma; postpartum depression; the winter season for seasonal affective disorder; little or no social support; low self-esteem; and lack of personal control over an individual’s circumstances. Additional risk factors are a family history of depression (parent or sibling); feelings of helplessness; using certain medications, including medications used to treat asthma, high blood pressure, arthritis, high cholesterol, and heart problems; smoking; anxiety; insomnia; personality disorders; and hypothyroidism.
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Etiology and Genetics (Genetics & Inherited Conditions)
Major depressive disorder is a condition in which multiple environmental and genetic factors play a contributing part. Some individuals are genetically predisposed to develop the condition, yet a detailed genetic analysis and prediction of inheritance patterns are not possible, since so many different genes seem to be implicated. It has been known for decades that depression tends to run in some families, and twin studies have confirmed that genetics plays a critical role. One study reports that in fraternal twins (who share approximately 50 percent of the same genes), if one twin develops depression the other will also be diagnosed with the condition about 20 percent of the time. In identical twins (who share 100 percent of the same genes), however, the rate of concordant diagnoses of depression rises to 76 percent.
Molecular genetics studies conducted during and since the completion of the Human Genome Project have identified several candidate genes that may play a role in the predisposition for or development of depression. There is considerable disagreement among the researchers, however, so the candidate genes in the following list must be considered as only possible contributing factors. The TPH1 gene, located on the short arm of chromosome 11 (at position 11p15.3-p14) encodes the enzyme tryptophan hydroxylase 1, which is important for the synthesis of serotonin (a neurotransmitter produced in the brain...
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Symptoms (Genetics & Inherited Conditions)
Depression can differ from person to person. Some people have only a few symptoms, while others have many. Symptoms can change over time and may include persistent feelings of sadness, anxiety, or emptiness; hopelessness; feelings of guilt, worthlessness, or helplessness; loss of interest in hobbies and activities; loss of interest in sex; tiredness; trouble concentrating, remembering, or making decisions; and trouble sleeping, waking up too early, or oversleeping. Other symptoms may include eating more or less than usual; weight gain or weight loss; thoughts of death or suicide, with or without suicide attempts; restlessness or irritability; and physical symptoms that defy standard diagnosis and do not respond well to medical treatments.
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Screening and Diagnosis (Genetics & Inherited Conditions)
There is no blood test or diagnostic test for depression. The doctor will ask about a patient’s symptoms and medical history, giving special attention to alcohol and drug use, thoughts of death or suicide, family members who have or have had depression, sleep patterns, and previous episodes of depression.
The doctor may also perform specific mental health exams; this will help get detailed information about the patient’s speech, thoughts, memory, and mood. A physical exam and other tests can help rule out other causes.
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Treatment and Therapy (Genetics & Inherited Conditions)
Treatment may involve the use of medicine, psychotherapy, or both. Severe depression usually requires hospital care and the use of drugs, such as olanzapine.
Up to 70 percent of depressed patients find relief from their symptoms with antidepressant medications, which can take two to six weeks to reach their maximum effectiveness. These medications include selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro).
The U.S. Food and Drug Administration advises that people taking antidepressants should be closely observed. For some, the medications have been linked to worsening symptoms and suicidal thoughts. These adverse effects are most common in young adults. These effects tend to occur at the beginning of treatment or when there is an increase or decrease in the dose.
Although the warning is for all antidepressants, of most concern are the SSRI class, such as Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram).
Another form of treatment is the use of tricyclic antidepressants, such as imipramine (Tofranil), doxepin (Adapin, Sinequan), clomipramine (Anafranil), nortriptyline (Pamelor), and mitriptyline (Elavil); and the use of monoamine oxidase inhibitors (MAOIs), such as phenelzine (Nardil)...
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Prevention and Outcomes (Genetics & Inherited Conditions)
Individuals can reduce their chances of becoming depressed by being aware of their personal risks; having psychiatric evaluations and psychotherapy, if needed; developing social supports; learning stress management techniques; exercising regularly; avoiding the abuse of alcohol or drugs; and getting adequate sleep, rest, and recreation.
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Further Reading (Genetics & Inherited Conditions)
Aguirre, Blaise A. Depression. Westport, Conn.: Greenwood Press, 2008.
Beck, Aaron T., and Brad A. Alford. Depression: Causes and Treatments. 2d ed. Philadelphia: University of Pennsylvania Press, 2009.
EBSCO Publishing. Health Library: Depression. Ipswich, Mass.: Author, 2009. Available through http://www.ebscohost.com.
Groves, D. A., and V. J. Brown. “Vagal Nerve Stimulation: A Review of Its Applications and Potential Mechanisms That Mediate Its Clinical Effects.” Neuroscience and Biobehavioral Reviews 29, no. 3 (May, 2005): 493-500.
Kramer, Peter D. Against Depression. New York: Penguin Books, 2005.
Linde, K., M. Berner, and L. Kriston. “St. John’s Wort for Major Depression.” Available through EBSCO DynaMed Systematic Literature Surveillance at http://www.ebscohost.com/dynamed.
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Web Sites of Interest (Genetics & Inherited Conditions)
“Antidepressant Use in Children, Adolescents, and Adults.” U.S. Food and Drug Administration. http://www.fda.gov/cder/drug/antidepressants
Canadian Mental Health Association. http://www.ontario.cmha.ca/index.asp
Canadian Psychiatric Association. http://www.cpa-apc.org
Depression and Bipolar Support Alliance. http://www.ndmda.org
International Foundation for Research and Education on Depression. http://www.ifred.org
Mental Health America. http://www.nmha.org
National Institute of Mental Health. http://www.nimh.nih.gov
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Causes and Symptoms (Magill’s Medical Guide, Sixth Edition)
The word “depression” is used to describe many different things. For some, it defines a fleeting mood, for others an outward physical appearance of sadness, and for others a diagnosable clinical disorder. In any year, more than twenty million American adults suffer from a clinically diagnosed depression, a mood disorder that often affects personal, vocational, social, and health functioning. The Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (4th ed., 2000) of the American Psychiatric Association delineates a number of mood disorders that include clinical depression, known as major depression.
A major depressive episode is a syndrome of symptoms, present during a two-week period and representing a change from previous functioning. The symptoms include at least five of the following: depressed or irritable mood, diminished interest in previously pleasurable activities, significant weight loss or weight gain, insomnia or hypersomnia, physical excitation or slowness, loss of energy, feelings of worthlessness or guilt, indecisiveness or a diminished ability to concentrate, and recurrent thoughts of death. The clinical depression cannot be initiated or maintained by another illness or condition, and it cannot be a normal reaction to the death of a loved one (some symptoms of depression are a normal part of the grief reaction).
In major depressive disorder, the patient experiences a major...
(The entire section is 959 words.)
Treatment and Therapy (Magill’s Medical Guide, Sixth Edition)
Crucial to the choice of treatment for clinical depression is determining the variant of depression being experienced. Each of the diagnostic categories has associated treatment approaches that are more effective for a particular diagnosis. Multiple assessment techniques are available to the health care professional to determine the type of clinical depression. The most valid and reliable is the clinical interview. The health care provider may conduct either an informal interview or a structured, formal clinical interview assessing the symptoms that would confirm the diagnosis of clinical depression. If the patient meets the criteria set forth in the DSM-IV, then the patient is considered for depression treatments. Patients who meet many but not all diagnostic criteria are sometimes diagnosed with a “subclinical” depression. These patients might also be considered appropriate for the treatment of depression, at the discretion of their health care providers.
Another assessment technique is the “paper-and-pencil” measure, or depression questionnaire. A variety of questionnaires have proven useful in confirming the diagnosis of clinical depression. Questionnaires such as the Beck Depression Inventory, Hamilton Depression Rating Scale, Zung Self-Rating Depression Scale, and the Center for Epidemiologic Studies Depression Scale are used to identify persons with clinical depression and to document changes with...
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Perspective and Prospects (Magill’s Medical Guide, Sixth Edition)
Depression, or the more historical term “melancholy,” has had a history predating modern medicine. Writings from the time of the ancient Greek physician Hippocrates refer to patients with a symptom complex similar to the present-day definition of clinical depression.
The rates of clinical depression have increased since the early twentieth century, while the age of onset of clinical depression has decreased. Women appear to be at least twice as likely as men to suffer from clinical depression, and people who are happily married have a lower risk for clinical depression than those who are separated, divorced, or dissatisfied in their marital relationship. These data, along with recurrence rates of 50 to 70 percent, indicate the importance of this psychiatric disorder.
While most psychiatric disorders are nonfatal, clinical depression can lead to death. About 60 percent of individuals who commit suicide have a mood disorder such as depression at the time. In a lifetime, however, only about 7 percent of men and 1 percent of women with lifetime histories of depression will commit suicide. Though these numbers are very high, what this means is that not everyone who is depressed will commit suicide. In fact, many receive help and recover from this illness. There are, however, other costs of clinical depression. In the United States, billions of dollars are spent on clinical depression, divided among the...
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For Further Information: (Magill’s Medical Guide, Sixth Edition)
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. Arlington, Va.: Author, 2000. This reference book lists the clinical criteria for psychiatric disorders, including mood disorders.
DePaulo, J. Raymond, Jr., and Leslie Ann Horvitz. Understanding Depression: What We Know and What You Can Do About It. New York: Wiley, 2003. A leading expert on depression examines the disease’s nature, causes, effects, and treatments.
Depression and Bipolar Support Alliance. http://www .dbsalliance.org. In addition to a comprehensive list of informative links, this site has information on mood disorders and support groups and offers lists of mental health professionals and discussion forums.
Jones, Steven. Coping with Bipolar Disorder: A Guide to Living with Manic Depression. Oxford, England: Oneworld, 2002. A handbook for living with bipolar disorder, outlining causes, symptoms, and treatments; giving case studies; and listing support organizations.
Koplewicz, Harold S. More than Moody: Recognizing and Treating Adolescent Depression. New York: Penguin, 2003. A leading clinician and researcher helps parents distinguish between normal teenage angst and depression, examining the warning signs, risk factors, and key behaviors, as well as treatment options.
National Institute of Mental Health. http://www.nimh...
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Depression (Encyclopedia of Cancer)
Everybody feels sad sometimes, but to be clinically depressed is not just a matter of feeling sad. A patient with cancer is diagnosed as having major depression only if certain symptoms, such as loss of pleasure or thoughts of death, are present for at least two weeks. Only a healthcare professional can accurately determine whether a patient is depressed or is simply upset because of the disease.
A note on depression and children with cancer
Few children with cancer experience depression. For many children survivors of cancer, the experience of having had cancer makes them deeper, more understanding human beings later in adulthood and old age. However, some children with cancer do experience depression, sleep problems, and relationship problems. Depression appearing in a child who has cancer should be treated by a healthcare professional.
The symptoms of depression in children are somewhat different from those in adults. The physician should be notified of a sad mood (or, in children less than six years of age, a facial expression that appears to express sadness) that continues for at least two weeks and is accompanied by at least four of the following: (a) appetite changes, (b) sleep problems or...
(The entire section is 3001 words.)
Depression (Encyclopedia of Genetic Disorders)
Depression is the general name for a family of illnesses known as depressive disorders. Depression is an illness that affects not only the mood and thoughts, but also the physical functions of affected individuals. Depressive disorders usually result from a combination of genetic, environmental, and psychological factors.
Everyone feels sadness, grief, or despair at some point in their lives. However, unlike these normal, transient emotional states, a depressive disorder is not a temporary bout of "feeling down" but rather a serious disease that should be recognized and treated as a medical condition. Without treatment, a depressive disorder can persist and its symptoms can go on for weeks, months, or years. The three most common types of depression are dysthymia or dysthymic disorder, major depression, and bipolar disorder.
Depression is quite widespread and one of the leading causes of disability in the world. Commonly recognized symptoms of all types of depressive disorders are recurring feelings of sadness and guilt, changes in sleeping patterns such as insomnia or oversleeping, changes in appetite, decreased mental and physical energy, unusual irritability, the inability to enjoy once-favored...
(The entire section is 2626 words.)
Depression (Encyclopedia of Neurological Disorders)
When discussing depression as a symptom, a feeling of hopelessness is the most often described sensation. Depression is a common psychiatric disorder in the modern world and a growing cause of concern for health agencies worldwide due to the high social and economic costs involved. Symptoms of depression, like the disorder itself, vary in degree of severity, and contribute to mild to severe mood disturbances. Mood disturbances may range from a sudden transitory decrease in motivation and concentration to gloomy moods and irritation, or to severe, chronic prostration.
With treatment, more than 80% of people with depression respond favorably to medications, and the feeling of hopelessness subsides. With treatment, most people are able to resume their normal work and social activities.
Depression may occur at almost any stage of life, from childhood to middle or old age, as a result of a number of different factors that lead to chemical changes in the brain. Traumatic experiences, chronic stress, emotional loss, dysfunctional interpersonal relationships, social isolation, biological changes, aging, and inherited predisposition are common triggers for the symptoms of depression. Depression is classified according to the symptoms displayed and patterns of occurrence. Types of depression include major depressive disorder, bipolar...
(The entire section is 1832 words.)
Depression (Encyclopedia of Science)
Depression is one of the most common mood disorders. Everyone experiences depressed moods from time to time. More commonly referred to as "having the blues" or "being down in the dumps," the sad or depressed mood usually lasts for only a short period. When the feeling persists for weeks without apparent reason, however, it may be a sign of major depression, a psychiatric disorder.
The symptoms of major depression include a sad or depressed mood or a marked lack of interest and pleasure in almost all activities. This feeling persists for most of the day, nearly every day, for at least two weeks. In addition, many or all of the following symptoms occur: (1) loss of appetite; (2) fatigue (tiredness); (3) difficulty sleeping; (4) feelings of guilt or worthlessness; (5) lack of concentration; (6) thoughts of death, often including suicidal thoughts or plans, or even a suicide attempt.
People with major depression are also very likely to experience headaches, stomachaches, or pains or aches almost anywhere in their bodies. Major depression affects twice as many women during their lifetimes as it does men.
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Depression (Encyclopedia of Psychology)
An emotional state or mood characterized by one or more of these symptoms: sad mood, low energy, poor concentration, sleep or appetite changes, feelings of worthlessness or hopelessness, and thoughts of suicide.
Depression may signify a mood, a symptom, or a syndrome. As a mood, it refers to temporary feelings of sadness, despair, and discouragement. As a symptom, it refers to these feelings when they persist and are associated with such problems as decreased pleasure, hopelessness, guilt, and disrupted sleeping and eating patterns. The entire syndrome is also referred to collectively as a depression or depressive disorder. At any given time about 10 percent of all people suffer some of the symptoms of depression at an economic cost of more than $30 billion annually and costs in human suffering that cannot be estimated. The American Psychiatric Association estimates that about one in five Americans experiences an episode of depression at least once in his or her lifetime.
Depression can generally be traced to a combination of physical, psychological, and environmental factors. Depressive disorders involve a person's body, mood and thoughts.
Genetic inheritance makes some people more likely than others to suffer from depression. More than 60 percent of people who are treated for depression...
(The entire section is 1447 words.)
Depression (Encyclopedia of Alternative Medicine)
Depression, also known as depressive disorders or unipolar depression, is a mental illness characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep, appetite, and mental processes are a common accompaniment.
Everyone experiences feelings of unhappiness and sadness occasionally. However, when these depressed feelings start to dominate everyday life without a recent loss or trauma and cause physical and mental deterioration, they become what is known as depression. Each year in the United States, depression affects an estimated 17 million people at an approximate annual direct and indirect cost of $53 billion. One in four women is likely to experience an episode of severe depression in her lifetime, with a 100% lifetime prevalence, compared to 50% for men. The average age a first depressive episode occurs is in the mid-20s, although the disorder strikes all age groups indiscriminately, from children to the elderly.
There are two main categories of depression: major depressive disorder and dysthymic disorder. Major depressive disorder is a moderate to severe episode of depression lasting two or more weeks. Individuals experiencing this major depressive episode may have trouble sleeping, lose...
(The entire section is 3052 words.)
Depression (Encyclopedia of Public Health)
Depression is sometimes referred to as the common cold of mental illness. It is a debilitating disease with significant societal costs. It is, however, one of the most clearly defined and treatable of mental illnesses. Technically, the term "depression" is used to cover a variety of symptomatic conditions, all characterized by negative mood and a loss of pleasure. Together these conditions comprise a spectrum ranging from major depression to dysthymia to adjustment reactions to normal grief and sadness. At one extreme of this continuum lies major depressive disorder, a syndrome characterized by severe episodes of depressed mood accompanied by loss of sleep, appetite, concentration, energy, and hope. The depressed mood must persist for greater than two weeks in order to warrant this diagnosis. At the other end of the continuum lies the diagnosis of dysthymia, which is characterized by a lower level of mood disturbance that persists chronically; that is, involving more days than not for a period of two years or greater. Many patients complain of depressed mood but do not fit neatly into either of these two categories. These patients' symptoms are frequently best accounted for as a reaction to an acute life stressor. These reactions are typically nonpathological and resolve with time, but they may constitute an adjustment reaction if normal functioning is sufficiently disturbed.
Depression is both common and costly. It has a lifetime prevalence of 5 to 10 percent of women and 2 to 5 percent of men. It is an expensive disorder in both direct and indirect terms, as depression causes a higher degree of functional disability than many medical illnesses including diabetes, chronic lung disease, and arthritis. Additional costs to society result from the effect of untreated depression on the treatment of medical illnesses, where it contributes to longer hospital stays and morbidity. This has been particularly well demonstrated in the treatment of myocardial infarction (heart attack), where the presence of major depression has consistently been found to increase mortality.
Depressive illness is thought to result from a combination of biological and psychological factors. The biological component is strongly suggested by the high genetic concordance of depressive disorders. In the twenty-first century, there are various competing theories about the nature of this genetic/biological contribution, but the available data do not yet indicate the specific nature of the illness. The psychological component is similarly suggested by the correlation of onset of major depression with negative life events and with the increased risk of depression in individuals who experienced abuse in childhood. A variety of psychological theories exist and are linked to models of psychotherapeutic treatment. Interpersonal psychotherapists, for example, emphasize the role of grieving due to the loss of an important relationship or a transition in social roles (e.g., transition from working to retirement, marriage to divorce). Cognitive therapists emphasize a mind-set of construing life events in a way that leads to depression. Alternately, psychodynamic therapists search for the ways that unconscious coping processes and repetitive relational patterns result in negative effects. A commonly postulated mechanism would include the turning of anger in on the self. For example, a depressed woman may feel critical of herself rather than direct her anger toward an abusive spouse.
Treatment of depression parallels theories of etiology in that both biological and psychological treatments exist and have been efficacious. A number of different antidepressant medications have been developed, including monoamine oxidase (MAO) inhibitors, tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRI). These medicines have demonstrated efficacy in both the treatment of acute depressive episodes and in the prevention of relapses. A variety of psychological therapies are also employed in the treatment of depression. Interpersonal psychotherapy and cognitive behavioral psychotherapy are psychotherapeutic models for which depression-specific therapeutic techniques have been developed. These tend to be delivered in the form of brief semi-structured treatments, lasting less than a year in duration. One advantage of these approaches is that they have been well tested in research settings and have an established record of effectiveness in appropriately selected patients. There is also some clinical consensus that long-term psychodynamic (emphasizing unconscious mental processes) therapies are also helpful, especially when the mood disorder exists in the context of a long-standing personality disorder.
STUART J. EISENDRATH
(SEE ALSO: Mental Health)
Eisendrath, S. J., and Lichtmacher, J. E. (1999). "Psychiatric Disorders." In Current Medical Diagnosis and Treatment 1999, eds. L. M. Tierney, S. J. Mcphee, and M. A. Papadakis. Stamford, CT: Appleton & Lange.
Gabbard, G. O. (1994). Psychodynamic Psychiatry in Clinical Practice: The DSM-IV Edition. Washington, DC: American Psychiatric Press.
Panzarino, P. J. (1998). "The Costs of Depression: Direct and Indirect: Treatment versus Nontreatment." Journal of Clinical Psychiatry 59(20):114.
Depression (International Dictionary of Psychoanalysis)
Depression is a mood disorder, understood from the psychoanalytical viewpoint as resulting from an intrapsychic conflict that stems from the ego's difficulties in integrating aggressive drives that are experienced as too dangerous for the preservation of libidinally cathected objects. These aggressive drives turn against the subject via the superego, which becomes too strict and demanding. Depressive manifestations are frequent in other clinical entities where the conflicts are essentially intrapsychic, such as the psychoneuroses.
Karl Abraham (1912/1989) was one of the first psychoanalytical authors to concern himself with depressed patients and to describe the extent of the ambivalence of their drives. Narcissism is another characteristic of the depressive personality, which that Freud emphasized in "Mourning and Melancholia" (1916-17g ). Subsequently, Abraham (1924/1927) described the pregenital underpinning of this ambivalence, given the importance of oral fixations in these patients.
Freud compared the psychological mechanisms of melancholia with those of mourning, which constitutes a depressive state in the normal person. The essential difference is the narcissism of the melancholic, whose intolerance of experiences of loss lead him to the oral incorporation of the lost object into the ego, where it is attacked by the superego. Conversely, the person in mourning finds himself faced with the painful difficulty of detaching the libido cathected onto the lost object so as to recathect it onto objects in the external world. However, the major problem raised by Freud's descriptions of the dynamics of melancholia is that he does not specify the variations in the psychological mechanisms corresponding to the different degrees of depressive states.
Melanie Klein (1940) developed the comparison with mourning in her description of the depressive position. For her, the capacity to work through one's mourning will depend on the possibility of resolving the reactivation of the conflict proper to the depressive position that the conflict causes, i.e., the feeling of losing good internal objects. Klein, like Freud, is imprecise when it comes to the different problematics of depression. However, clinical analysis shows a whole series of levels of severity in this problematic between the working through of the mourning process (or during the integration of the depressive position) and the peak of this process, which Klein described as "a melancholia in statu nascendi" (Palacio Espasa). These depressive forms of conflict can be defined by reference to the predominant form of the fantasies expressing the experiences of the loss of the object of libidinal cathexis, and by the quality of the types of anxiety experienced by the ego.
When fantasies of the catastrophic and irreparable destruction of the object predominate, given that the subject has very little confidence in his libidinal capacities, feelings of guilt become intolerable and feelings of sadness are massively denied. The ego can only resort to archaic mechanisms of defense: splitting, denial, projective identification, idealization, etc.he mechanisms proper to schizo-paranoid functioning or to the dynamics of extreme melancholia, with confusion between the ego and the object attacked (the "parapsychotic" depressive conflict proper to borderline or psychotic structures).
When fantasies of severe and barely reparable damage or death of the objects take the upper hand, the ego will be confronted with intense feelings of guilt and sadness. The significant repression of the aggressive drives towards the object (an aggressiveness that reinforces the severity of the superego) will make it possible for the negative affects to be partially denied. The ego will succeed in keeping the conflict interiorized but at the cost of diverse inhibitions in the functions of the ego. Thus, the symbolic possibilities of the individual are limited, but are not qualitatively affected. This very narrow form of repression is often insufficient, and the ego also has to resort to maniacal defenses or to defenses of a melancholic type, which then determine the clinical manifestations of mood disturbances.
When feelings of abandonment and rejection prevail.e., when the experiences of loss are above all fantasies such as the loss of the object's loveepressive conflict will take a "paraneurotic form." The feelings of sadness are often conscious, for guilt is less intense and can equally easily become conscious. The ego's greater confidence in its libidinal capacities gives these subjects a profusion of fantasies of reparation that will counteract the damage done to the object, damage that is fantasized as resulting from their own aggressiveness. These fantasies underlie many of the neurotic mechanisms of defense, especially those of an obsessional kind, for example retroactive cancelling, reaction formation, etc. Under their influence, repression authorizes a greater possibility of symbolic expression, which distinguishes neurotic repression from the massive repression of the depressive type. Such a libidinal predominance changes the nature of what is repressed, for the counter-cathexis does not operate on aggressiveness alone, but also on the libidinal fantasies of an incestuous nature. This contributes to the sexual differentiation of parental objects, bringing into operation the conflict occasioned by triangulation and the Oedipus complex.
FRANCISCO PALACIO ESPASA
See also: Abandonment; Acute psychoses; Adolescent crisis; Anaclisis/anaclitic; Anxiety; Dead mother complex; Depressive position; Essential depression; Guilt, unconscious sense of; Identification; Internal object; Lost object; Manic defenses; Mania; Melancholia; Mourning; "Mourning and Melancholia"; Psychoanalytical nosography; Self-punishment; Suicide; Superego; Transference depression.
Abraham, Karl. (1927). The process of introjection in melancholia: two stages of the oral phase of the libido. In Douglas Bryan and Alix Strachey (Trans.). Selected papers of Karl Abraham, M.D. (pp. 442-452). London: Hogarth. (Original work published 1924)
. (1927). Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. In Douglas Bryan and Alix Strachey (Trans.), Selected papers of Karl Abraham, M.D. (pp. 137-156). London: Hogarth and the Institute of Psycho-analysis. (Original work published 1911)
Freud, Sigmund. (1916-17g ). Mourning and melancholia. SE, 14: 237-258.
Klein, Melanie. (1940). Mourning and its relation to manic-depressive states. International Journal of Psycho-Analysis, 21, 125-153.
Palacio Espasa, Francisco. (1993). La Pratique psychothérapique avec l'enfant. Paris: Bayard.
Depression (Encyclopedia of Drugs, Alcohol, and Addictive Behavior)
The term depression has been used to refer both to an emotional state and a group of psychiatric disorders. As an emotional state, it is also known by various comparable terms: dejection, despair, sadness, despondency, lowering of spirits. Cognitions (perceptions and judgments) of a negative nature often accompany depressed mood.
Most people experience brief periods of depressed or despondent mood, often in response to a disappointing life event. Each individual utilizes different COPING skills and relies on available social supports to deal with such episodes, which generally pass within hours to days.
When a dysphoric mood becomes more severe, is persistent, and impairs functioning, a major depression as a clinical syndrome has developed. Concurrent clinical features include a loss of interest or pleasure in usual activities, a sense of hopelessness, poor or alternatively increased sleep, loss of appetite or overeating with resultant changes in weight, fatigue, anxiety, restlessness, obsessive thinking, difficulty concentrating, irritability, feelings of worthlessness, recurring thoughts of death, and suicidal ideation or an actual attempt to end one's life. Suicidal disturbances are of serious concern; approximately 66 percent of depressed patients contemplate suicide, and it is estimated that 10 to 15 percent succeed. In some cases, psychotic features such as hallucinations and delusions may develop.
Depression is one of the most common psychiatric disorders seen in adults. The lifetime prevalence of major depressive disorder (using DSM-III-R criteria) in the United States is estimated to be 12.7 percent in men and 21.3 percent in women. Some individuals suffer from chronically depressed mood of a less intense nature than that experienced in a major depressive episode; this is referred to as dysthymia. A depressive syndrome may occur as part of manic-depressive illness, and depression as a symptom (i.e., a depressed mood) can be found in many other psychiatric disorders.
Depression should be distinguished from the normal despair of bereavement and from the various medical disorders (e.g., Parkinson's disease) and chemical agents (e.g., alcohol or drugs for heart conditions) that can produce symptoms of depressed mood. The cause of depression is unknown. Biological factors (e.g., dysregulation of neurotransmitter systems), genetic factors, and psychosocial factors (e.g., life events, learned behaviors, and cognitions) have been proposed, and it is likely that all interact to varying extents. Depression is a treatable (but not really curable) illness in the vast majority of people. Treatment consists of a number of modalities, depending on the type and severity of the depression. PSYCHOTHERAPY, anti-depressant medications, and electroconvulsive therapy are the main interventions used.
(SEE ALSO: Causes of Substance Abuse; )
GRUENBERG, A. M., & GOLDSTEIN, R. D. (1997). Depressive disorders. In A. Tasman, G. Kay, & J. A. Lieberman (Eds.), Psychiatry, 1st ed. Philadelphia, PA:W. B. Saunders Company.
KELLER, M.B. (ED.) (1988). Unipolar Depression. In A. J. Frances & R. E. Hales (Eds.), American Psychiatric Press review of psychiatry (Vol. 7). Washington DC: American Psychiatric Press.
KESSLER, R. C., ET AL. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-19.