Table of Contents
Depression is a disease of the whole body system that begins psychologically and more often than not results to emotional turmoil. It involves a person’s moods, thoughts and body, and affects a person’s belief about him/herself and other things in his/ her background. Unlike many illnesses, depression cannot be tested in the laboratory. However, physicians can accurately diagnose depression by testing and observing the symptoms. DSM-IV is the commonly used criteria for classifying and confirming depression. Extreme feelings of sadness, hopelessness and helplessness may indicate depression. Though everyone experiences grief, for normal people, such feelings usually disappear after sometimes, probably after a day or two. For a depressed person, the feelings prolong, and may cause hallucinations or suicidal thoughts. (American Psychiatric Association, 2000).
Depression is a serious illness that needs treatment and if not treated, leads to other disorders that are life threatening or even suicide. Additionally, if not treated, depression becomes more intense and may last for months or years, leading to other disorders such as major depressive disorders, anxiety disorders and bipolar disorders. A person suffering from depression may experience changes in their behaviors, thoughts, feelings and physical wellbeing. Characteristic depression symptoms concentration problems, extreme pessimism, low motivation, irritability, change in appetite and chronic fatigue. Since depression begins in the mind, and affects the whole body, this paper will show the extent to which depression is a psychological or biological anomaly. It also investigates the interaction between biological, social and psychological factors in causing depression. Major depressive disorder is clinically and etiologically heterogeneous. This complicates the understanding of its pathophysiology. Selected theories reviews are based on studies involving neurotransmitters, psychosocial anxiety and stress hormones (Armitage & Conner, 2000). . The monoamine theory is concerned with the interactions within the brain that lowers a number of neurotransmitters, especially serotonin. A reduction in their number may cause abnormal activities in the brain, which may lead to depression. The renowned cognitive theory revolves around damaged reasoning processes such as maladaptive thoughts, inaccurate information process and perceptions. These eventually affect a person’s behavior and interaction, thereby leading to depression. Psychological theories include both psychodynamics and psychoanalysis. They describe the psychological set up and the interactions between specific psychological dimensions.
There different types of depression depending on the severity of symptoms, common features and duration. The classification is by the mental disorder diagnostic and statistical manual, DSM-IV. DSM-IV is a report from the American Psychological association, which describes the acceptable criteria for psychiatric disorders. The DSM describes the following three depression variants: major depressive disorder, dysthymic disorder and manic mayhem. The symptoms of these disorders cause significant distress. Major depression is also known as clinical or principal depressive disorder, and is the most common type of depression. This depression usually occurs when similar depression symptoms last for two weeks, appearing every day. These symptoms include a depressed mood, significant weight loss, fatigue, lack of interest in activities and feelings of worthlessness.
Dysthymia is another type of depression, in which case the person may demonstrate a depressed mood for a long time, usually lasting for at least two years. Other symptoms of dysthymia include low self esteem, hopelessness feelings, fatigue and change in sleep patterns. Dysthymia symptoms vary in occurrence (MacFarlane, 2003). Though it is repeated, its symptoms are less serious. The last one is manic depression, which is clinically referred to as bipolar disorder. This depression involves alternating periods of extreme depression and mania. Most patients experience suicidal thoughts and the suicidal rate is extremely high for patients suffering from bipolar disorder. The individual may suffer from an inflated self esteem, talk persistently and experience racing thoughts. Depression disabilities depend on the severity of the depression. People suffering from mild depression may be distressed by these symptoms but will resume normal activities. Performance in social or work activity reduces with the severity, and the person may go through self neglect and become suicidal. The physical effects of depression include physical pains, somatic illnesses and chronic fatigue.
Causes of Depression
It is arguable that depression is only a condition of the mind. Physicians argue that depression is not entirely a biochemical issue, but a combination of several factors. It proves that many factors contribute to depression; personality traits, biological factors, genetics, sociocultural factors and the environment. Consequently, no single theory fully explains depression and no single treatment can address all depression cases.
Research to elucidate the causes of depression has been carried out. However, extensive research has been carried out in locating the presence of genes that cause depression (Wade & Kendler, 2000). A set of genes has been identified to relate to depression. It has been confirmed that some genes lead to depression in some families while the corresponding genes have no effect on other families. This group of genes predisposes an individual to depressive disorders, making it easy for the person to be depressed. One such gene is 5-HTT, which also aids in the regulation of serotonin. There are long and short forms of this gene that an individual may inherit. A person with an inherited short form of this gene is more likely to suffer depression when combined with traumatic life events compared to people with the long form. A person’s susceptibility to depression does not guarantee that the person will suffer depression.
To understand depression, one must understand the brain and its functions since the biological process is initiated in the mind. This means that a good understanding of the brain’s anatomy especially neurotransmission can enhance the assessment of depression. The limbic system and the forebrain are the key brain areas involved in depression. Damages to the cerebral cortex, which controls the thought process, will most likely cause abnormalities leading to negativism. Other organs responsible include the pituitary gland and hypothalamus. These two control crucial hormonal levels. An abnormal increase in these hormones such as epinephrine and serotonin is known to cause mood alteration. This ultimately culminates in depression. In addition, there will be activation of the hypothalamus-pituitary adrenal axis if there is tension, and this also leads to depression. The human brain contains more than 10,000 million nerve cells which are interconnected for nervous transmission. There are more brain connections that help in the transmission of impulses or messages across organs through synapses. For this transduction to be effective, neurotransmitters need to be well regulated. The major neurotransmitters involved in neurotransmission are serotonin and norepinephrine. This approach is explained in the monoamine theory.
The monoamine theory argues that depression is sometimes caused by lack of monoamine-dependent neurotransmissions. This theory gained prominence in the 1950s after the realization that treatment with antihypertensive drugs increases chances of suffering depression. This is because these drugs deplete neurons that are responsible for transmitting monoamine. This leads to a shortage of monoamine, which may lead to depression. Later, this theory was supported with the availability of antidepressants which were found to increase levels of serotonin, dopamine and norepinephrine. A decrease in the activity of serotonin may cause unusual activity in the neurotransmitter systems that are associated with depression.
Biological approaches also involve an analysis of the contributionof the genetic component in depression. This approach suggests that there are high chances for people whose parents suffered depression to suffer too, especially if they are exposed to the causal factors. Studies involving twins have also shown that genetic factors also contribute to the development of depression. There are at least 45% chances of identical twins sharing mood disorders as compared to a 12% chance for fraternal twins. Similarly, people who are genetically susceptible to depressive disorders tend to have recurrent problems or suffer related illnesses. For some people, these disorders are inherited. However, for such cases, there are always reinforcing elements such as a depressive environment. Although there are research studies that prove the existence of depressive genes, their effect and probability to cause depression is extremely minimal. Depression will only be possible if other causal factors are present.
Another explanation for depression is from the behaviorists' school of thought in the cognitive theory. ‘Cognitive’ refers to mental processes like feeling and thinking. Theorists from this school explain that depression is as a result of irrational, maladaptive or faulty cognitions. These are mainly manifested in form of distorted thoughts or judgments. Cognitive theorists argue that people can develop these distorted thoughts from their social environments especially upon exposure traumatic events. Similarly, such cognitions may arise from inadequate coping skills. Cognitive theorists also explain that there is a significant difference in the thought process of a depressed and a non depressed person. In most cases, depressed people are pessimistic about their environment, their future and generally aspects of life. Consequently, their interpretations about issues are always negative, and they engage in self blame whenever things go wrong.
According to a cognitive behaviorist, Aaron Beck, depression is caused by dysfunctional beliefs, which lead to negative thoughts. He also found a strong correlation between the amount of negative thoughts a person has, and the severity of the depression. In addition, Beck identifies three fundamental schemas that are dominant in a depressed person’s thinking; they view themselves as inadequate. Moreover, their experiences are seen as failures and their futures as hopeless. When put together, the schemas are known as a negative cognitive triad. Negative thoughts also influence what an individual pays attention to, as they tend to pay attention to negative things. Such individuals avoid recognizing positive deeds. This takes a toll on their perceptions on themselves as well as surroundings. Albert Bandura also explained depression in his social cognitive theory. In this theory, Albert explains that the interactions between people’s environmental events, thoughts, and behaviors usually shape their lives. Usually, depressed people have a different self concept from normal people. Their thoughts are distinctly characterized by self blame and pity (Garcia & Mann, 2003).
One theory that is effective in explaining depression is the bio-psychosocial theory. This approach considers psychological, biological and social factors in explaining human functioning. It posits that human health is best explained as an interaction between social, biological and psychological factors. The biological bit of this approach focuses on the causes of illness that originate from body functioning. The psychological part investigates potential psychological factors such as negative thoughts, while the social component looks at the social issues such as poverty and religion.
Psychological theories explain people’s behavior, feelings and thinking. These theories combine interpersonal relationships, personality factors and history, in their explanation of depression causes. One such theory is the psychodynamics theory, whose focus is on the interrelationships of the mental, psyche, emotions and motivations. These elements mould a person’s personality. Sigmund Freud explains that the human mind is divided into preconscious, the conscious and unconscious. The unconscious comprises the id, ego and the super ego. The id of the mind gives people irrational thoughts is impulsive and selfish. The ego is the rational part that bridges the gap between the super ego and the id. The super ego internalizes societal norms. When there is a conflict between the conscious and the unconscious, individuals go through repression. Repression makes the individual unaware of hidden desires or motives, which are psychologically harmful. These hidden emotions affect the person’s moods, interactions and perception of their surroundings. These hidden emotions may accrue from childhood traumas or developmental fixations that remained unresolved. It is necessary to resolve these issues if the individual seeks a healthy mental state. Psychoanalysis is another of Freud’s explanations of depression. In earlier explanations, psychoanalysts say that when a person converts anger into self hate, that person is most likely to be depressed. However, after evolution, a branch of this came up; a theory called “objects relations”. This one focuses on how people perceive things and the mental representation of their relationships with others. People’s personality aspects are understood within the context of their relationship with others and their experiences. This theory also asserts that a person’s early life relationships form a basis for their later relationships. Thus, depression occurs when the person fails to establish healthy representations relationships Gatchel & Oordt, 2003).
It is a consequence of the struggle an individual will have, when trying to maintain psychological contact with their desired objects. This may be represented either in anaclitic or introjection patterns. In an anaclitic pattern, the person will feel dependent on relationships. When the relationship ends or there is a threat to the stability of the relationship, the person grieves. Grieving usually ends in depression as he/she feels helpless and hopeless. Conversely, introjection depression is observed when an individual views him/herself as a failure, especially when they feel that they have not met their standards or those of their loved ones. Personality and development aspects are also critical in the acquisition and maintenance of depression. Although stressful events are correlated with depressive episodes, an individual’s coping style also corresponds with his /her resilience (Carlson et al., 2001).
Current qualitative studies focus on the salience of both social and cultural factors in explaining depression. Sociocultural factors are those forces in our cultures or society that influence our behaviors, feelings and thoughts. They may include family structure, religion, gender and gender roles, poverty, ethnic values, race, kinship structure and child rearing practices. For example, women in some countries have internalized some cultural messages and gender-driven expectations to the extent that their perceptions about themselves are solely dependent on such internalizations. They compare themselves to various cultural standards that define them as “good wives” or “good mothers” (Jack, 2003). For most people, family is a significant contributor to their depression. The family marks the most immediate social unit they have. Problems at the family level may increase the chances of acquiring depression. Spouses suffer unipolar mood disorders as a result of having relationships characterized by hostility, lack of affection or friction (Gotlib & Hammen, 1992). In addition, women usually experience varied emotions when they have children. This may become stressful as they struggle to maintain relationships with their spouses and new born. Similarly, a parent’s psychological setting affects the children. A depressed parent may affect the child, leading to depression in children (Hammen & Brennan, 2001).
Culture shapes our perception about ourselves, others, and the environment. Culture dictates the way an individual socializes and what seems ‘normal’ or ‘acceptable’ through cultural norms and values. Some of these values may be stressful to ordinary people, who may struggle to live within the cultural norms to gain acceptance. Failure to achieve these values or live within these norms may isolate the individual, leading to feelings of failure. Unrealistic or idealistic cultural expectation or philosophies may drive an individual into depression. For example, expectations on perfection demand a lot of self sacrifice from individuals. Sometimes these demands may require an individual to prioritize the needs of others. This makes them to ignore their own needs of growth and self care. These idealistic ideas usually create extreme standards for performance on individuals. Once the individual faces reality and realizes how high those standards are, they become susceptible to depression. Industrial societies with low levels of social rituals may facilitate the development of postpartum depression. Child bearing usually involves a myriad of emotions and feelings. New mothers need to adjust to their new roles positively through the help of the society and family. Cultural practices that help mothers adjust will lower their levels of developing depression. Such practices include allowing them time by giving them some amount of social seclusion and recognition and encourage the society and family to assist them with tasks (Jack, 2003).
Attachment theorists also explain causes of depression from the attachment point of view. They argue that the quality of early life bonds determines mental stability and coping ability. Changes in families may also predispose one to suffering depression. For example, children whose parents go through a divorce are at higher risks of suffering mood disorders and personality problems. As seen early in cognitive explanations, perceptions of healthy relationships are key contributors to depression. This closely relates to the socialization explanation of depression in socio-culture. The socialization of an individual determines how well the individual can manage stressful situations, how they form and maintain relationships, and their interpretation of reality. A person’s social setting and social class also play a key role in depression. A depressed person seems to have a negative impact on his/ her social setting, and this strongly impacts on social interactions (Gatchel & Oordt, 2003).
Gender is another notable sociocultural factor in depression. In most depression surveys, women and girls are vulnerable to depression disorders. The World Health organization termed poverty as the greatest cause of suffering. Poverty is a fundamental variable influencing mental health. In its worst case, poverty is distressing and alienating, hence having either a direct or indirect impact on the development of psychiatric problems. The problems of poverty are manifold in causing depression. It causes social inequality, which inhibits socialization and gives room to negative perceptions of the self. In addition, it causes psychosocial stress, which may lead to deterioration of life and general health. Poor people are exposed to stressful agents such unrewarding work, dangerous environments, lack of social amenities, and isolation. However, this does not imply that rich people do not suffer depression.
To affirm the validity of these studies, physicians usually involve medication, psychotherapy, and sometimes, electroconvulsive therapy in the treatment of depression. Since they understand that depression is both a medical and social issue, treatments usually involves a combination of psychotherapy and antidepressants. Antidepressants vary in the manner in which they affect the level of neurotransmitters in the brain. Most antidepressants inhibit the reuptake of serotonin, dopamine or norepinephrine. These antidepressants have varied side effects and should only be described by qualified medical doctors. Some of them cause withdrawal while others are not suitable for people suffering certain illnesses such as liver diseases. Similarly, depression can be treated using other medications such as anti-anxiety medications, stimulants, anti-psychotic medication or mood stabilizing medication. For better performance, sometimes combine two or more medications. This synergistic process is referred to as augmentation (MacFarlane, 2003).
Psychotherapy is another effective treatment for depression. Psychotherapy is psychological counseling, involving a series of sessions between the patient and a therapist. In psychotherapy, the patient learns about depression through the therapist. By offering this understanding to the patient, the therapist makes it easy for patients to identify unhealthy changes in their thoughts and behavior. Upon this realization, they are better placed to apply appropriate interventions. The therapist also explores past relationships or experience that may have been repressed by the patient and allows patients to talk and release hidden emotions. In addition to these, the therapist assists the patient to set realistic goals in the cause of the healing process. Appropriate suggestions are made to cope and solve problems.
Psychotherapy is mainly based on cognitive behavioral therapy and the psychodynamics theory. Psychodynamics therapy focuses on releasing repressed feelings and thoughts from past experiences that cause unconscious conflict. Cognitive behavioral therapy assists the patient to identify negative behaviors and thoughts that facilitate the development of depression. Once the patient identifies these negative thoughts and beliefs, the therapist helps him/her replace them with positive ones. These therapies may be given individually, in a group, with the family or spouses. Individually, the sessions involve the therapist and the patient. In group therapy, the therapist may put together two or more patients for sessions at the same time. In this form of therapy, patients are able to share their experiences and learn from each other. Marital therapy enables spouses to understand depression, and how to help each other to cope better. It also helps the non depressed spouse to cope well with the ill spouse. Family therapy aids family members to cope well with the depressed family member after gaining insight on depression. Electroconvulsive therapy involves the administration of electrical currents on the patients’ brain to stimulate the actions of neurotransmitters. Electroconvulsive therapy is mainly used in cases where the patient fails to respond to medical treatment or other therapies. This therapeutic approach is mainly utilized in patients exhibiting suicidal tendencies especially if they are not responding to other forms of treatment. In extreme cases of depression, patients are hospitalized.
Depression is a serious disease that impacts adversely on the functioning of the whole body. Though it is a psychological disorder, depression may end up affecting an individuals’ sleeping, eating and socializing ability. This concern has led to the widespread research on the aetiology of depression. Research has in turn led to development and advancement of theories to explain various causes and therapeutic approaches of depression. This paper has explained the main theories i.e. cognitive, bio-psychosocial, psychoanalysis, monoamine, and psychodynamics. These theories confirm that depression is not wholly a disease of the mind, rather a combination of interrelated factors. While biological theories explain how genetic and the maladaptive brain function facilitate the development of depression, this is not solely responsible for depression to occur. Other factors such as low self esteem, poverty, poor information processing, poor cultural practices and socialization are fundamental contributing factors. Hence it is not automatic that a bereaved will suffer depression. However, if the bereaved person faces other challenges such as cultural practices that do not support healthy grieving, lacks effective coping skills, and have poor information processing, then the person is likely to suffer depression. To support the claims that depression is largely a result of stressors in the mind, environment and socialization, physicians use a combination of therapeutic approaches to treat depression. The report has briefly described the treatment strategies used for depression. They include cognitive behavioral therapy, psychodynamics therapy, medication, and electroconvulsive treatment.