What We Know About Depression

Depression is the most common mood disorder in the United States and, indeed, the world. It is a problem growing in scope and severity, and according to the World Health Organization as well as cross-national epidemiological surveys, the rise in the rate of depression around the world is a leading cause of human suffering and disability (Klerman & Weissman, 1989; World Health Organization, 2001). The costs of depression on a variety of levels are huge: Marriages and families splinter, individuals suffer, societies suffer the consequences of the often destructive behaviors of people coping badly or not at all with their depression, businesses suffer the negative effects of employees too disabled to function properly, greater health care expenses for depressed patients lead to enormous economic costs, and societies experience the tragedy of suicides and lives lost to despair and apathy. Depression is a terribly disabling disorder, and despite significant advances in treatment, the problem continues to grow in scope rather than diminish. It is a sad fact that most of the people who need help don't get it.

Depression is a multidimensional disorder. It has biological components based in genetics, neurochemistry, and physical health, and it has psychological components that involve many individual factors such as cognitive style, coping style, and qualities of personal behavior. And it has social components, factors that are mediated by the quality of one's relationships, including such variables as the family and culture one is socialized into, and one's range of social skills. The best, most accurate answer to the basic question "What causes depression?" is "Many things."

Although there are many pathways into depression (these may involve gender differences in susceptibility, age and cultural differences, and many other differences as well), once someone is depressed the demographic differences become far less significant. Once you're depressed, it feels lousy no matter what your age, race, religion, gender, or socioeconomic status. Thus, to a clinician trying to catalyze recovery, such factors are secondary. Empowering the person to better manage whatever his or her unique vulnerabilities might be is primary.

Depression is a highly comorbid condition, meaning that it is more often found to coexist with other conditions (medical and/or psychological) than it is found existing on its own. Some form of anxiety disorder is the most common comorbid condition, but other disorders are also common, such as substance abuse (especially alcoholism), eating disorders, personality disorders, and scores of medical conditions. The fact that depression is a highly comorbid condition is well represented in this volume, with chapters addressing depression and anxiety, pain, posttraumatic stress disorder, eating disorders, and Asperger's syndrome.

Currently, the medical model of depression receives the greatest attention for a variety of reasons. The pharmaceutical industry in particular has spent many billions of dollars in advertising to the public as well as investing directly in individual psychiatrists, encouraging all to define depression as a disease caused by a neurochemical imbalance that requires medication to manage. There are currently nearly two dozen antidepressants available, and many more are currently in various stages of research and development. The lion's share of research money goes to drug research, further elevating drugs to the status of being the source of hope for everyone who suffers depression. Considered a first-line treatment approach by many mental health professionals, antidepressants are widely prescribed, thereby either deemphasizing the value of psychotherapy or ignoring it altogether.

There is a growing backlash against the one-dimensional depiction of depression as a biologically based disease. There is already abundant and irrefutable evidence that many other factors, both personal and social, play profound roles in both the onset and course of depression (Pettit & Joiner, 2006). To ignore these factors and emphasize only biology is highly misleading. When clinicians so oversimplify depression, people are misguided into believing they don't have to change themselves or their lives in any way, but need only change their biochemistry. When one underestimates the complexity of the problem, solutions will inevitably be incomplete, leading one to predict that the rate of depression will continue to rise. And so it does. It may sound extreme to some, but I stand by this statement: Depression is more a social problem than a medical one, and no purely biological cure will be found for it any more than biology alone will cure other social ills such as poverty or child abuse. There are things psychotherapy can do that no amount of medication can do, and some of these are the focus of the chapters in this book.

When there have been psychologically based treatments that match the success rate of medications and even surpass them in specific ways, that have lower rates of relapses, and that do more to make people feel better in the treatment process and can even be applied successfully in programs of prevention, there is more than sufficient reason to emphasize the value of psychotherapy in treatment. But not all psychotherapies are of equal merit. Some have clearly demonstrated a greater efficacy in the realm of depression, namely, those therapies that emphasize skill acquisition (such as coping skills or social skills) and require the client to actively engage in the treatment process in a goal-oriented way. Behavioral activation is the term commonly used to emphasize the importance of the client taking sensible, purposeful action to do something different in order to recover. This is not to say that antidepressant medications shouldn't be a part of treatment, especially in those specific instances where there are clear benefits medication can provide over psychotherapy. Rather, medications should be used more carefully and with an associated recommendation for a well-considered psychotherapy.

The social side of depression is especially important yet is terribly under-considered in the field. We know, for example, that depression runs in families: The child of a depressed parent is anywhere from three to six times more likely to become depressed than the child of a nondepressed parent. Thus, a depressed parent is a large risk factor (Goodman & Gotlib, 2002). The genetics research makes it quite clear that faulty genes are not entirely responsible, especially because there is no "depression gene." It has more to do with the patterns of thinking, coping, behaving, and relating that parents (and other significant role models in our society) model day in and day out than with one's genetic makeup. When you have the largest demographic group of depression sufferers, namely, the 25- to 45-year-olds, raising children, it should surprise no one that they are raising the fastest growing group of depression sufferers. After all, parents can't teach their children what they don't know. Furthermore, the more distressed one's marriage is, the more likely one is to either already be or become depressed. The quality of one's marriage is a very large risk factor, yet many clinicians never explore this vital part of a client's world. These points provide excellent reasons for wanting to strengthen parents and marriages, something no antidepressant medication alone can accomplish (Yapko, 1999). To think of depression as only an individual's disorder, as if he or she isn't a product of powerful social forces that operate in families, organizations, and cultures, or to reduce it even further to a purely biochemical phenomenon, is so terribly reductionistic as to disempower the very people we purport to serve.

The significance of pointing out that there are many pathways into depression should be elaborated. By the time depression strikes, the risk factors have been in place for years. (See my book Treating Depression with Hypnosis, 2001, Brunner/ Routledge, for a fuller discussion of this point.) It is tempting to look for a single cause (such as your genes or your recent job loss), but these represent events. Depression is not generally an event-driven phenomenon; rather, it is a process-driven one. Its origins and course are evident in the process, the "how" of how the person thinks, copes, problem solves, relates, behaves, eats, moves, and does lots of other things that hold the potential to either insulate them against depression or land them in the middle of an episode (a theme addressed by several of the chapters in this volume). It will not escape your notice that virtually all the experts in this book target processes (such as information gathering or decision making) with their hypnotic interventions rather than just symptoms or hypothetical causes.

The prevention of depression is an especially important consideration (including the prevention of relapses, as discussed in the final chapter). The fact that programs have been established in a variety of contexts that have a proven ability to prevent depression is some of the strongest evidence we have for thinking of depression as a largely learned phenomenon (Seligman, 1995). To teach people the skills they will need to cope with the inevitable stresses of life (i.e., the hurts, rejections, disappointments, and losses we all face; the problems we must all solve; and the challenges we all must transcend), and then demonstrate that by learning such skills one's vulnerability to depression is significantly reduced, represents an extraordinary opportunity. The still rising rates of depression make it clear, unfortunately, that we have not yet seized that opportunity, to the detriment of us all.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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