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Depression. Depression has been called the common cold of mental illnesses. Current estimates from the National Institutes of Mental Health (NIMH) suggest that each year more than 11,000,000 people in the United States suffer from this illness. A national study (Kessler, 1994) of more than 8,000 people aged 15 to 54 found a lifetime rate of 17% for major depression (21% among women and 13% among men) and a rate of 5% when people were asked whether they had been depressed in the previous month. If these statistics remain accurate, one of every five women and one of every eight men will suffer from major depression during their lifetime. In addition, a recent cross-national comparison (Cross National Collaborative Group, 1992) compiling the data of 12 studies from nine countries, and involving interviews with 43,000 people, indicated that the major rate of depression has risen steadily in much of the world during the twentieth century. In response to the increasing prevalence of depression in the United States and elsewhere, research efforts have been focusing more attention than ever before on the causes and treatment for depression.

However, the term depression needs more explanation. The current psychiatric glossary of mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association (1994) and commonly referred to as DSM-IV, lists major depression as only one of a larger related cluster of mood disorders. Suffice it to say depression differs greatly among people in its symptomatology, severity, and duration. Major depression and the associated mood disorders are further defined in the following section.

Depression also should be distinguished from what many of us experience as a bad mood, or from the normal grief reaction to the loss of a loved one or loved object. Bad moods, which often diminish during the course of a day or two, and normal grief, which may last beyond a period of a year, usually do not consistently interfere with work, friendships, family life, and physical health. More serious depression, however, sometimes referred to as clinical depression, interferes with and disrupts a person’s job and relational life. The usual amounts of cheering up, exercise, prayer, vitamins, or vacation leave have little or no impact on this form of depression. People with clinical depression need to get proper treatment, which usually includes medication, psychotherapy, or a combination of both.

Depression and the Mood Disorders. The DSM-IV lists major depression, bipolar disorder, dysthymic disorder, and cyclothymic disorder as the primary disorders of mood. Major depression, also called unipolar depression, is identified by sad, empty, or hopeless feelings; slowed physical and cognitive behavior, including cognitive disorientation; changes in weight, appetite, and sleeping patterns; diminished interest or pleasure in activities and time spent with friends; and occasional to frequent thoughts of death and suicide. The presence of several of these symptoms for a period exceeding two weeks and a marked change from previous functioning are sufficient criteria for a diagnosis of a major depressive episode. Psychotic symptoms (delusions or hallucinations) are not common but do occur in about 15% of patients with major depression. According to one recent study (Update, 1994) the average major depression lasts four months. More than half of the people with one depressive episode will have a second, and 80% of people with two episodes will have a third.

Bipolar disorder, popularly called manic depression, is identified by alternating cycles of depression and manic elation. The length of cycle, the degree to which either depression or mania is present during a cycle, and the frequency of shifting between moods vary considerably in a bipolar disorder. The manic phase, when it is extreme, often resembles some forms of schizophrenia. As a result it can be very difficult to accurately diagnose a bipolar disorder at the onset. Manic phase symptoms include increased energy, inappropriate excitement or irritability, increased talking or moving, promiscuous sexual behavior, racing thoughts, impulsive behavior, and poor judgment, such as spending sprees or unrealistic plans or goals. These symptoms are often accompanied by grandiose thoughts and an inflated self-esteem.

Dysthymia and cyclothymia are related to major depression and bipolar disorder respectively in that each resembles a less severe but more chronic form of the latter. These disorders may be likened to a low-grade infection. For example, individuals diagnosed with a dysthymic disorder may never feel really good; they may go through the motions of daily life for years with little pleasure or enthusiasm. A cyclothymic disorder, by contrast, involves numerous periods of manic symptoms coupled with numerous periods of depressive symptoms. These symptoms are present for at least two years, but they are not as intense, nor do they meet all of the criteria for a classic bipolar illness.

Seasonal affect disorder, popularly known as SAD, is another closely related condition. SAD is a major depressive or bipolar disorder that recurs with a distinct seasonal pattern, excluding the obvious effect of seasonal related psychosocial stressors. This form of depression has been related to the brightness and duration of daylight, and in some cases has been successfully treated with artificial light therapy combined with medication.

The DSM-IV outlines each of these disorders in the section entitled mood disorders and supplies the more detailed criteria required for accurate diagnosis and treatment. A complete diagnosis involves careful attention to the onset, duration, and frequency of symptoms as well as accompanying features. When these factors are taken into account, there exist twelve distinct different forms of mood disorders. A copy of the DSM-IV should be available at a local library or Community Mental Health agency.

In addition to the DSM-IV, several well-known pencil-and-paper inventories can assist in the diagnosis of depression. Beck’s Inventory for Measuring Depression (Beck, 1967), Zung’s Self-Rating Depression Scale (Zung, 1973), and the Hamilton Rating Scale for Depression (Hamilton, 1960) are among the most common. The first two are self reporting, while the latter uses the scoring of two independent raters. In general these instruments are best used as screening tools or in conjunction with a clinical examination. They are not intended as a primary means of diagnosing major depressive illness.

Theories of Depression. Many general theories have been developed to explain how early family life, learning and cognition, social circumstances, and biology might produce a clinical depression. The best known are psychodynamic, behavioral, cognitive, systemic (family), and biological theories.

Psychodynamic Theories. These theories stress the resultant anger present when early dependency needs are frustrated (see Fenichel, 1945). Dependency needs can be unmet or frustrated in several ways. A child may experience actual or perceived parental rejection through autocratic and rigid parenting, experience the loss of a parent (especially mother) at an early age through death or divorce, or experience abusive or neglectful parenting (see Abuse and Neglect). Whatever the cause, intense feelings of loss and anger can result. At early ages children are not consciously aware of anger. If partial awareness is experienced, there still remains the problem of directing anger in a nondestructive manner. The frustration over unmet needs cannot be directed at the object of the anger but rather is directed to the inward or introjected image of that person. This is because the lost love object is either no longer available or is too threatening a figure. This introjected image is a part of the self in analytical terms, but it has yet to be adequately assimilated into the life of the individual. Consequently a loss or stressful experience in later life may reactivate the anger and cause a kind of delayed grief. The accompanying self-criticism and guilt (i.e., “anger is bad”) are often expressed through symptoms of depression.

Fenichel (1945) also noted that dependency plays a major role in a psychodynamic understanding of depression. Depressive individuals are very dependent, showing a desire to passively meet needs and to react violently when such needs are frustrated. Depressive individuals interact with others in clinging or helpless ways that induce others to take care of them. This childlike dependency or helpless and hopeless pattern that follows the loss of a loved one or object is a postulate in most psychological theories of depression. Consequently psychodynamic treatment for depression will include an exploration of past events to discover unresolved painful experiences and the resultant anger that appears to be related to depressive symptoms.

Behavioral Theories. The nature of response patterns in an individual’s behavioral repertoire is emphasized in this theory. Depression is described as a lowered frequency of adjustive responses to daily life. Compared to the normal person’s responses to life, the depressed person’s responses are fewer and slower. The depressed person may sit silently for long periods or perhaps stay in bed all day. The time taken to reply to a question may be longer than usual, and speaking, walking, or carrying out routine tasks will also occur at a slower pace. By its very nature such behavior will lead to a reduction in gratification. The depressed person’s repertoire is also a passive one. It is marked by the effort to escape or avoid any uncomfortable or aversive social consequences.

Ferster (1973) suggests that a depressive response pattern can be elicited by a number of events: a high level of exposure to aversive events and the need to avoid aversive situations (e.g., consider the situation of the biblical character Job or Jonah); a low level of positive reinforcement (i.e., “no news is not always good news”); a sudden decrease in reinforcement from a significant source that has controlled a large amount of behavior (e.g., retirement or the death of a loved one); repeated exposure to a situation that requires much effort to gain even a little reinforcement (e.g., living under unrealistically high standards of performance); and the expression of anger that annoys other people and consequently denies the individual positive reinforcement. Since all of us experience some of these situations from time to time, the frequency and duration of these aversive experiences will distinguish people who are vulnerable to depression.

Furthermore, it is important to note that not everyone who is vulnerable to depression will become depressed. Behavioral theorists describe a cycle of depressive behaviors that tends to perpetuate itself. The low availability of reinforcement leads to depressive symptoms, which in turn lead to social avoidance, which ultimately perpetuates even lower levels of reinforcement. Consequently, successful treatment for depression will break into this process at some point and reverse its downward spiral. The primary goal of behavior therapy for depression is to help the depressed person increase the frequency of positive adjustive behavior and ultimately restore much-needed reinforcement.

Cognitive Theories. Depression is best described in these theories as a disorder of thinking. The philosopher Epictetus wrote that “men are not moved by things, but the view which they take of them.” Ellis (1962) believes that most emotional disturbances arise from faulty thought processes. The depressed person has distorted beliefs about life that are sustained by automatic thoughts submerged in partial awareness. These thoughts are brief and may be only a word or two, yet they appear with regularity and create a form of negative self-talk that gives a running commentary on one’s immediate experiences. This negative talk has its roots in what Beck (1976, p. 84) described as a cognitive triad of depression consisting of a negative view of the world, a negative concept of the self, and a negative appraisal of the future. The triad represents the essence of a depressed person’s faulty thinking. All of us have some characteristic distortions in our thinking, but depressed persons consistently see the world, themselves, and the future through dark-colored glasses.

One common cognitive distortion is polarized thinking, or the all or nothing approach to life. A student may believe that a grade of A is the only acceptable grade. Consequently a grade of B or C is grouped with grades of D and lower. Grades then come in only two forms: acceptable (A) or unacceptable (B and lower). Other common cognitive distortions are usually identified through the therapy process. The treatment of depression with cognitive therapy will include the discovery and challenge of faulty thinking or distortions anywhere they are found.

A second major cognitive theory of depression is learned helplessness. Seligman (1975) formulated the concept based on a discovery involving animal research. Animals underwent a series of painful experiences (shocks) from which they could not escape. After repeated exposure to the experiments, the animals gave up even trying to escape and reduced their behavior to passive whimpering. When they were placed in trial runs where escape was a possibility, the animals believed they could not influence their environment (escape) and accepted the shocks. Applied to human behavior, learned helplessness is that state in which the individual comes to believe that nothing can be done about a present painful experience. For example, if a teacher were to pull grades out of a hat and assign them to students at random, the students would soon learn that nothing they did by way of work or study would influence their grade. It is easy to see how a person faced with this scenario might develop depressive symptoms. Perhaps readers can think of a few situations where people may feel they have little or no control. Successful therapy, directed toward reducing learned helplessness, must assist people in discriminating between controllable situations from those which are beyond one’s control.

Systemic Theories. These theories interpret individual behavior, including depression, to be a function of one’s interaction within the larger system (family). Applied mostly to the field of family therapy, depressive symptoms in a family member would be considered a sign that the entire family has an ailment. Consequently a member of a family who is experiencing depression is acting as a spokesperson for the family. A child’s depression may be linked to a stressful marital relationship; a mother’s depression may be linked to the children’s leaving home and the father’s preoccupation with work; a father’s depression may be related to the unresolved grief accumulated over several past generations within his own family of origin.

An important distinction of systemic theories when compared to individual theories is the emphasis upon circular causality (see Watzlawick, Beavin, & Jackson, 1967, p. 46). In other words, individual behavior is more often a product of the interactions of an individual with other members of a shared system that comprise a series of never-ending feedback loops (i.e., member A influences member B, who influences A, who in turn influences B). For example, a young adult’s efforts to leave home may make one parent anxious. The parent responds by attempting to move closer emotionally to the child. The child, who at this developmental stage of life needs greater independence, reacts by pushing further away from the parent. The parent becomes more anxious and increases efforts at moving closer to the child. If the anxious parent’s efforts are successful in thwarting the child’s natural move toward independence, depression may arise as a symptom in the child. Add family members C, D, and E to the equation, and the possibilities become myriad. This circular model is in contrast to the linear approaches of causation used in most individually oriented theories (e.g., A causes B causes C). Therefore, depression in a family member is seen as the entire family’s response to the peculiar stressors of that family. Systems therapy will consider the symptom of depression within the context of the family and be directed at changing the interactions between family members that will eliminate the need for one of its members to be symptomatic. This type of reasoning can be applied to other individual symptoms, so that systemic thinking can be a way of interpreting other mental disorders.

Biological Theories. The role of genetic factors and brain chemistry is normally considered in these theories. Evidence for a genetic basis of mood disorders is largely supplied through comparison studies of monozygotic (identical) and dizygotic (fraternal) twins. Identical twins show a high rate of concordance with bipolar illness but a lower rate with unipolar depression when compared to fraternal twins. For example, Price (1968) found that in 66 of 97 pairs of identical twins, when one twin was diagnosed with a bipolar illness, so was the other. However, fraternal twins showed identical diagnosis in only 27 of 119 pairs. Moreover, the concordance levels for unipolar depression are even less for both identical and fraternal twins. The implication is that genetic factors play a stronger role in the causation of bipolar depression.

While it is generally agreed that genetic factors are linked to depressive illness, the mechanism responsible for the link is less clear. It is currently believed that genes exert their influence primarily by altering or modifying biochemical activity in the brain. The most prominent biochemical theory is the catecholamine hypothesis (see Adams, 1982, p. 418). According to this theory, depressive illness is associated with the amount of neurotransmitters (chemical substances) available at the synapse (a gap between neurons) site. The essence of brain activity is the firing of electrochemical impulses across neurons (nerve cells). Neurotransmitters facilitate this activity in the brain. Between 35 to 40 neurotransmitters have been identified in neuron activity. The availability of three of these appears to be closely related to depression. An insufficient amount of the catecholamines norepinephrine and dopamine or the idolamine serotonin at the synapse site has been strongly linked to depression. Conversely, an excessive amount of these may help explain the manic features in a bipolar disorder. The current antidepressant medications have the effect of increasing the availability of one or more of these neurotransmitters at the synapse.

Other Related Causes. Brandt (1988, p. 189) states that certain dysfunctions of the endocrine system can be chief sources of depression. Specific failures of the thyroid gland (hypothyroidism), the adrenal glands (affecting sodium and electrolyte balance), and pancreas (hypoglycemia) have all been related to the onset of depression. A thorough medical examination is usually recommended before diagnosing major depression and undertaking lengthy psychotherapy or treatment with antidepressants.

Lack of nutrition also can be an overlooked cause of depressive symptoms, and laboratory tests can identify specific vitamin deficiencies. Multiple vitamin and mineral (usually in megadoses) and amino acid supplements can be useful in such cases. The picture is complicated by the fact that depression can also contribute to nutritional deficiency. Emotional distress interferes with the proper absorption of vitamins, minerals, and amino acids, which in turn alter the availability of neurotransmitters. The question of which comes first is not an easy one to address and goes beyond the nutritional deficiency debate. Even when biochemical abnormalities are found to be causal agents in a person’s depression, it is difficult to determine if depressed thinking has caused the biochemical changes or whether the chemical imbalances cause the depressed thinking.

Reviewing the numerous theories and related causes of depression might lead the reader to wonder which, if any, are the correct ones. Each theory explains depressive illness from a particular vantage point, and each related cause has supportive evidence. Furthermore, treatments based upon each have had some success in treating those suffering from depression. Each theory also has its limitations; none satisfactorily accounts for all manifestations of the mood disorders. As a result most experts believe in a biopsychosocial causation of depression. This means that the symptoms of depression are most likely caused by a combination of biological, psychological, and social factors, each of which contributes to a final common pathway to depression.

Treatment for Depression. The standard treatments for mood disorders are psychotherapy, medication (antidepressants), and electroconvulsive therapy (ECT, sometimes called shock therapy). It is difficult to specify psychotherapy techniques that are consistently superior in the treatment of depression. Perhaps this is because psychotherapy cannot be reduced to mere techniques but is best described as part science and part art. The chemistry between a client and therapist may have as much to do with successful treatment as the particular techniques employed by the therapist. The NIMH recently undertook what may have been the most careful comparative study (Update, 1995) of psychotherapy in history. Patients with major depression were assigned to one of four treatments: an antidepressant, a placebo, interpersonal therapy, and cognitive therapy. Interpersonal therapists emphasize the immediate social context of depression and the depressed person’s relationships with other people. Cognitive therapists, as mentioned earlier, focus on correcting faulty thinking. Patients in all four groups improved; however, there was some indication that the combination of medication and some form of therapy was more effective than medication alone. Most experts believe that medication combined with a course of counseling offers the best possibility for successful treatment. It should be remembered that most research of this sort is conducted only on major depressive illness. Further research is needed to study the effectiveness of treatments for the other mood disorders (e.g., bipolar disorder or dysthymia).

Three main classes of medications are currently used for the treatment of depression: the tricyclics (TCAs), which increase the availability of norepinephrine and serotonin at the neuron synapse; monoamine oxidase inhibitors (MAOIs), which increase transmitter norepinephrine and dopamine; and the most recent addition, the selective serotonin reuptake inhibitors (SSRIs), which increase the availability of serotonin at nerve endings. Each has been shown to be generally effective in the treatment of depression. The differences between these medications arise mostly in experienced side effects. It is important to remember that each of these medications acts idiosyncratically with the users. For example, individuals taking the same tricyclic antidepressant (there are several available) may experience different side effects. Also, MAOIs, while effective, can produce a dangerous rise in blood pressure when taken at the same time as tyramine, a substance found in cheese, red wine, and other foods. All TCAs, if taken in an overdose of ten times the daily prescription, can be lethal. These drawbacks have led to the popularity of the newly released SSRIs, currently available under the popular names Prozac, Zoloft, and Paxil. These are not lethal if taken in overdose, and the noted side effects are fewer and less severe for the SSRIs. Contrary to popular opinion, none of the antidepressants is habit-forming. They do not cause euphoria, and they will do little more than offer a few temporary side effects if taken by a person who is not depressed.

Physicians and psychiatrists normally prescribe antidepressants for a period of four to six months to a year. If one medication proves ineffective or its side effects are unacceptable, the doctor will likely prescribe another antidepressant. There is some trial and error involved in finding the most effective antidepressant, since at this time it is not known whether one is experiencing a depression related to a deficiency of serotonin, norepinephrine, or dopamine.

There are several other means of increasing the availability of neurotransmitters associated with depression. They are often overlooked because they are common and practical: proper exercise and nutrition. Proper exercise decreases vulnerability to the effects of stress (which deplete neurotransmitters), and proper nutrition provides the natural manufacturing of essential neurotransmitters. Brandt (1988, pp. 247–266) offers a guide to vitamin and food supplements that may assist one in overcoming depression. These obvious means of maintaining our physical and mental health need to be taken seriously when normal functioning has been disrupted.

Electroconvulsive Therapy. ECT is accomplished by passing an electric current through the brain to create an artificial epileptic seizure (the rapid firing of neurons throughout the brain). The procedure was introduced in 1938 and admittedly has not received a great deal of public support. In novels and films (e.g., One Flew Over the Cuckoo’s Nest) it has been associated with attempts to subdue subversives. Discomfort with the convulsions occurred during the seizures, the severity of which would sometimes cause sprains and bone fractures. Drugs are now administered to make the patient comfortable and to relax the muscles. The procedure is painless and relatively safe. ECT is most often used for severely depressed patients who do not respond to other forms of treatment. Its effectiveness has also been shown on a limited basis for mania and schizophrenia. ECT may be the choice of treatment for some patients who cannot take medications for health reasons.

Pastoral Counseling and Spiritual Help. Medieval counselors saw depression as a sin to be fled. Current popular opinion among Christian counselors varies from treating depression as primarily a spiritual problem (Adams, 1970; LaHaye, 1974; Lloyd-Jones, 1965; Solomon, 1971) to considering it more an affliction of the body-mind that eventually oppresses the spirit of its victim (Minirth & Meier, 1978; White, 1982). The matter is further complicated by widely differing opinions on the nature of the spiritual life. Those who believe that the primary stumbling blocks to a healthy spiritual life are manifested in the subtle lies of this world will be careful to search the Scriptures and life for signs of the pure, holy, and true. Those who conceptualize spiritual health in terms of overcoming spiritual oppression may consider depression as an attack from the evil one.

White (1982, chap. 10), a Christian psychiatrist, believes that it is difficult to know if and when a person’s depression is mainly a spiritual matter. He cites the case of a man who was relieved of depression through an understanding of the grace of God. Yet he added that “among the thousands of patients I have treated … he is the only seriously depressed person whose psychological needs were met by a spiritual understanding. More frequently I see spiritual understanding restored by psychiatric treatment” (p. 201). White acknowledges the importance of humans as spiritual beings created in the image of God and considers clinical depression a malady that often distorts one’s spiritual understanding. It may also be impractical if not impossible to distinguish a spiritual depression from one caused by stress, disrupted affectional bonds, genetic vulnerability, or physiological imbalances. Efforts at separating the body and soul have led to much confusion throughout history, and the same is true when attempting to explain depression as an either/or phenomenon.

However, Brandt (1988) suggests three spiritual sources of depression: God-Void or the loss of an illusion, God-Neglect or the loss of fellowship, and God-Confusion or the loss of peace. Although these are problems of spiritual content, Brandt considers them ultimately the result of wrong thinking (p. 94). This may explain the popularity among many Christian counselors of the cognitive approach to depression. A number of Christian authors (e.g., Crabb, 1977; Backus & Chapian, 1980) have published popular helps for depression using a cognitive approach that allows for the use of Scripture as a guide to remedy the spiritual sources of depression.

White (1982) further reminds pastoral counselors of their important role in counseling a depressed person. It is the role of a patient encourager. The pastor is in a unique position to assist depressed persons in the congregation in fighting off the debilitating guilt that often accompanies depression. Moreover, this guilt is intensified by the idea that spiritual people do not become depressed. The pastor can help explain the numerous causes of depression and its ability to hold people almost helplessly within its grasp. Referrals for professional help can also be an important part of the pastor’s role as caregiver. If depression has its roots in helplessness and hopelessness, the pastor can surely be a messenger of hope.

M. D. Lastoria