Introduction
People may experience mild stages of distress over time brought about by loss; it could involve family, job losses and even broken relationships. Sadness may diminish over time, while clinical depression may persist over longer periods of time. Depression is a disorder in an emotional state just like sadness; it can be conceptualized as feelings of low moods lasting for long periods of time (Wolpert, 2008). Genetic factors are a key determinant of the changes in both behaviour and body.
The cornerstone of evolutionary theory is survival for the fittest (Wolpert, 2008). Thus, people adapt over time based on the surrounding environment. With this in mind the causes and determinants of various illnesses can be understood as biological. However, social causes do exist. This essay delves into the history of depression, diagnosis, management, and also the social, biological, and psychological side of the illness.
History
Sigmund Freud developed psychoanalysis in the early 20th century to treat depression (Harris, 2001). In his writing, he advocated for the release of unconscious thoughts and emotions. The psychoanalysis school of thought believes that psychological problems including depression emanate from the unconscious mind (Harris, 2001).
The first diagnostic tool for depression was apperceived in 1952 through the publishing of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Updates on the manual occurred in 1968, 1980, 1987, and 2000. However, critics assert that the reliability of the manual is debatable because interpretations of the various mental problems differed among therapists. Furthermore, in 1952 doctors discovered medication to treat depression while examining patients with tuberculosis.
This led to widespread use of medication in patients as opposed to psychotherapy as earlier times. The presence of factors that trigger depression are the same, but these manuals do not distinguish extreme sadness from depression cultures; as they have different physical symptoms (Wolpert, 2008). In addition to the use of medication after this period (1950’s), other schools of thought emerged besides that of psychotherapy. Consequently, clinical depression treatment and management involve a myriad of techniques.
Nowadays, a combination of the various techniques is used in treatment by therapists. This suggests that biological and also social aspects of depression have to be taken into consideration when investigating causes of depression.
Culture
Perceptions on the disorder are not unanimous with most non western cultures seeking minimal medical remedies (Karasz, 2005). The popularity of the biopsychiatric model in western society contrasts with the situational model of non western societies. Depression in such circumstance is socially constructed. Similarly, ethnic minorities in western world view depression as emanating from social problems. Therefore, they seek treatment less than Caucasians.
Culture influences the detection and treatment of depression. Similarly, the social environment affects depression rates; however, studies on the prevalence of depression in different cultural settings are few. Patel (2001) asserts that researches on non-western cultures are seen as unscientific while research on western culture is viewed as scientific.
Depression has remarkable differences between different cultures. The meaning of depression is normally lost in non western languages as the feeling of sadness. Equally, the use of mental disorder may seem better, but it connotes people in a mental asylum.
Karasz (2005) asserts that the majority middle class white population viewed depression as a disease and consequently sought attention of mental health experts. On the other hand, ethnic minorities regarded the issue as one involving social and emotional matters. The biopsychiatric model, which emphasizes biology and heredity as determinants of depression, is common in western societies while the situation model, which expressed depression as depending on social matters, is widely accepted in non western societies.
Religion
Dein (2006) studied the link between spirituality and depression and their impact on depression; he concluded that religion has a positive role in reducing incidences of depression at the same time religious individuals appeared to recover faster from depression. He further suggests that the association of depression with hopelessness necessitates research on the link with spirituality; this is because spirituality aims to address homelessness.
Intrinsic religion, which does not look into the advantages of religion, leads to better mental health in contrast to people who join extrinsic motivation that seeks religion for the benefits pertaining to it.
The study established an inverse relationship between religion and depression, but the use of cross sectional data meant conclusion of causality was not plausible. Additionally, the distinction of religion from spirituality is vague. There is need also to take qualitative studies into whether religion has other mechanism, which impacts on mental health.
The evidence of effects of religion on mental illnesses suggests the need to integrate religious viewpoints in mental health assessment and treatment. Dein (2006) points out that using Christian cognitive behavioural therapy achieves better results than others. Religion is socially constructed rather than biological with religious leaders and adherents obeying the teachings of a religion.
Diagnosis
There are various diagnostic tools available for depression among them Beck Depression Inventory, General Health Questionnaire and the Zung Depression Scale. These tools use a cut off point to evaluate the extent to which patients are depressed. Further screening and diagnosis should be conducted since at times the self reports can be biased. Nevertheless, the scales are useful as they give insights on the cognitive thoughts of the patients.
Remick (2002) states that depression affects more women than men, while the likelihood of depression increases when close relatives have depression. Consensus on the correlation with age is nonetheless murky because there is no agreed diagnostic protocol. This further complicates diagnosis since most people in depression do not seek medical treatment. Suicide was found to be high among depressed patients as well as risks of disability.
The Beck Depression Inventory (BDI) formulated in 1961 provides a guideline on the extent of depression. It involves questions regarding physical symptoms and emotions in depressive individuals. Self report is used for adults only where a score above 30 indicates severe depression while scores below 9 indicate depression is minimal. Translation of the questionnaires to other languages raises the issue of validity due cultural bias. In a study of the diagnostic reliability of BDI-II and DSM IV, Voikli et al (2008) found out that diagnosis of hypersomnia, a depressive disorder, was satisfactory.
Recently, the significance of brain imaging in examining the causes of depression has gained wide coverage. The imaging technology provides scientists with the privilege of observing changes in the brain structure without performing surgery. Comparisons of images between depressed persons and those without the disorder provide knowledge on changes in behaviour. Magnetic Resonance Imaging (MRI) is useful since it provides three dimensional pictures of body structures and organs through magnetic fields and radio frequency.
Diagnosis of depression is not a clear cut issue since there are no clinical tests, but rather diagnosis relies on symptoms like sadness, lack of sleep or too much sleep. Thus, diagnosis ought to first include examination of symptoms depending on the evaluation of medical practitioners or therapists and history of the patient. Upon evaluation then appropriate management and treatment of depression follow.
Causes
Depression is most likely caused by a combination of biological, social and psychological factors. The biological influences of depression could be due to genetics, hormones or through the neurotransmitter pathway. On the other hand, social and psychological factors are related to traumatic social events and negative thought patterns (Ascortt et al., 2008).
Biological
Studies of the presence of depression were conducted between identical twins and fraternal twins. For identical twins, depression likely occurred to one of them when the other was depressed. On the other hand, fraternal twins had a likelihood of 19% being depressed when the other was depressed. Additionally, even when identical twins are raised in different homes they were more likely to be depressed like the other. This supports the notion that depression is more biological than social as evidenced by depression in twins who live separately (Remick, 2002).
Depression is more likely to occur where close blood relatives have a history of depression than if the disorder does not appear among family members. Furthermore, where parents and siblings have alcohol dependency then the probability of depression also increases. Studies have not pinpointed the genes thought to bring depression.
However, having depressed members does not necessarily mean that one will be depressed (Remick, 2002). Genetic factors are therefore, hypothesized to be passed across generation lines. This genetic predisposition is biological with the environment playing a lesser part.
Hormonal imbalance and impulses cause depression particularly in women; this relates to estrogen levels where high levels can trigger feelings of depression. Postpartum depression can occur after birth due to low estrogen and progesterone levels. Among adolescents, the hormonal imbalance can equally create depression for both males and females. In men, testosterone injection to the body for sports can lead to depression when reduction occurs.
To understand depression, researchers focus on the study of neurohormones and their role in influencing depression. The higher the cortisol levels the higher is the depression rates in patients. Similarly, the hypothalamus and pituitary glands show remarkable differences for depressed women.
Cortisol interacts with gonadal hormones in women with a history of postpartum depression; this depression occurs in the aftermath of giving birth in some women. Thus, hormonal impulses can have drastic effects on women’s depression even estrogen and progesterone (Ascortt et al, 2008).
Another explanation offered in support of the role of hormones in depression is that levels of depression appear similar for both pre puberty boys and girls and among elderly men and women. However, debate rages as to whether the real reason for the similarity is due to hormones or social reasons. Nevertheless, the increased rate of depression in teenage girls goes hand in hand with development of the hypothalamic, gonadal system and pituitary glands (Ascortt et al, 2008).
Some women experience hormonal changes during menstruation and consequently suffer from premenstrual dysphoric disorder (PMDD). For the older women the onset of menopause is accompanied with hormonal changes, which can also cause depression (Ascortt, 2008).
Harris (2001) found out that losses in life that did not result into humiliation were less likely to cause depression. Crucial to psychosocial is the origin of traumatic events in life and the corresponding effects. This calls for distinction between dependent events and independent, which occur beyond the control of the individuals. Dependent events were seen to be influenced by genetic make up and personality type. Additionally, the presence of a depressing environment might make residents to be depressed despite not experiencing the events themselves.
Neurotransmitters like dopamine, norepinephrine and serotonin regulate moods in individuals, thus, giving credence to the biological explanation of depression. Early in the 1960’s drugs were manufactured based on the idea that they would alter the biochemical monoamine hence treating depression. Serotonin affected stimulus in patients, while dopamine affects aggression. Use of drugs that increases noradrenaline leads to reduced depression. The understanding of this helps to treat depression and mood disorders in patients (Remick, 2002).
Psychosocial
These factors link depression with the people’s behaviour and thoughts. This is supported by the cognitive school of thought that depressed persons view their surroundings and prospects negatively due to their thinking. Hostility and dependency behaviour also leads to depression; such individuals try to create situations where they can be hostile or dependent. Negative thoughts in turn, lead to feelings of hopelessness and depression engulfing people’s life. The behaviour of persons may lead to low self esteem. Therefore, some people are vulnerable to depression due to their thought patterns (Harris, 2001).
Past traumatic events in childhood may trigger depression in the adult life permanently; the risk increases where there is drug abuse and limited social support. These effects are long lasting in some instances leaving one with feelings of guilt and worthlessness. The corresponding treatment depends on time that has elapsed since the event and the traumatic experience (Harris, 2001).
Social causes of depression such as the traumatic events can lead to depression by altering the body’s response to similar events; this causes depression (physically) to the patient. Similarly, people can develop depression due to stressful every day events. Other causes of depression could be due to side effects of prescription drugs by affecting brain functions.
Management
The management of depression depends on the type and severity of the condition; this includes the use of antidepressants or psychotherapy
Antidepressants
This is mostly useful to mild and severely depressed persons. Therefore, extra caution should be exercised while administering. If an initial antidepressant therapy fails then a patient will more likely respond to second trial. Symptoms seem to decline from a fortnight to about a month since medication (Remick, 2002).
Patients are encouraged to continue with medication even when better signs occur. Furthermore, the biological model supports this view where if one drug is unsuccessful then switching to another is recommended. Upon the failure of specific medication, then adequate time is required to reduce the side effects before another drug trial begins.
Depression reappears in more than 70% of patients due to early discontinuing of antidepressant therapy. Maintenance therapy should thus be administered to avoid relapse, death or disability (Remick, 2002). To minimize the risk of relapse, patients ought to continue with antidepressant therapy for not less than six months. Therapists ought to get consent from patients, in rare cases of continuous antidepressant therapy where patients with frequent bouts of depression are those above the age of 50 or who have almost unmanageable depression (Remick, 2002).
The professional gives his assessment based on the behaviour and emotions exhibited by the patient. Cognitive therapy, which focuses on altering behaviour interpersonal therapy attempts to enhance empathetic feelings while behaviour therapy aims to impact on feelings through change of behaviour.
Cognitive Behavioural Therapy (CBT)
Cognitive therapy relates to the change of behaviour to limit depression through thoughts, equally the therapist looks into coping mechanisms of the patient. Behaviour may be learned and hence effective training helps to achieve this. As thought patterns begin to change, patients learn skills to enable them avoid the negative thoughts.
It is helpful to patients who are resistant to medication. This therapeutic method supposes that depression is social through behavioural change than biological. Behaviour therapy involves the change in behaviour just like cognitive thoughts. However, it does not involve changes in emotions and thoughts. Paykel (2001) says that earlier studies show the effectiveness of CBT since there were lower rates of relapse for patients who had already undertaken antidepressant therapy.
Paykel (2001) recognizes the importance of interpersonal therapy (IPT) due to its wide use. However, use of IPT was found more effective when the drug amitriptyline was used to the extent that withdrawal reduced with the continued use of the drug. Interpersonal therapy involves relationships, as opposed to behaviour changing like in other psychotherapies.
The psychiatrist diagnoses the problem given the history of the patient and subsequently offers treatment. This treatment comes to an end when the patient progresses independently. Therapists aim to modify the identified interpersonal problem where coping mechanisms are also offered.
Electroconvulsive Therapy
ECT is particularly useful under severe depression and more than 60% of the patients have responded well to this therapy (Remick, 2002). Patients who are suicidal and are unresponsive to antidepressant therapy respond better to ECT than to therapy. Patients receive the treatment under anaesthesia, where treatments may range from six to twelve (Yatham et al, 2010). This shows that the method involves a biological function than social situations.
A study conducted by Yatham et al (2010) found that the use of ECT reduced serotonin receptors in the brain with marked changes on the right side of the brain. The effect on brain receptors led to the conclusion it is the cause for reduction in depression.
Alternative Treatment
Light therapy is one of the alternative treatments for season affective disorder that appears in fall or winter. It is normally administered at for not less than thirty minutes in a day through exposure to artificial light. The treatment is useful for mild depressions while its effectiveness on non seasonal therapies is not clear. Another alternative is the use of the herb St John’s Wort, for treating mild moods (Remick, 2002).
Conclusion
Depression affects people’s lives, body functions, and behaviour. The diagnosis of depression ought to adhere to the guidelines of DSM –IV; the biological explanations of depression require biological solutions through the administration of anti depressants. However, the psychosocial causes should not be ignored.
Thus, the use of both anti depressants and psychotherapy should be encouraged for such cases. Effective management of depression integrates the patient’s general medical history, depression history, and the surroundings. Risk factors should hence be minimal to enhance effectiveness of treatment.
Reference List
Ascortt, E. et al. (2008). Women and Major Depressive Disorder: Clinical Perspectives on Causal Pathways. Journal of Women’s Health, 17(10).
Dein, S. (2006). Religion, Spirituality and Depression: Implications for Research and Treatment. Primary Care and Community Psychiatry, 11(2), 67-72.
Harris, T. (2001). Recent Developments in Understanding the Psychosocial Aspects of Depression. Oxford Journals, British Medical Bulletin, 57(1) 17-32.
Karasz, A. (2005). Cultural Differences in Conceptual Models of Depression. Social Science & Medicine, 60, 1625–1635.
Patel, V. (2001). Cultural Factors and International Epidemiology Depression and Public Health. Br Med Bull, British Medical Journal (2001) 57 (1): 33-45.
Paykel, E. (2001). Continuation and Maintenance Therapy in Depression. British Medical Bulletin, 57, 145-159.
Remick, R. (2002). Diagnosis and Management of Depression in Primary Care. Canadian Medical Association Journal, 167(11), 1253-1260.
Voikli, G. et al. (2008). Hypersomnia in BDI-II: Clinical and Demographic Features. Annals of General Psychiatry 2008, 7 S235.
Wolpert, L. (2008). Depression in an Evolutionary Context. Philosophy, Ethics, and Humanities in Medicine, 3(8).
Yatham, L. et al. (2010). Effect of Electroconvulsive Therapy on Brain 5-HT2 Receptors in Major Depression. British Journal of Psychiatry, 196, 474-479.