Major Depressive Disorder
"Depression has been labeled the common cold of psychopathology" (Gilbert, 1992, p. 3). This abnormal state includes "changes in appearance, attitude, behavior, and thinking" (Ostow, 1970, p. 12). Depression is America's number one emotional illness, and it is rising (LaHaye, 1974). One in six people in the U.S. has a depressive episode in their lifetime (Womens Health Channel, 2003). "In the opinion of many researchers, more human suffering results from depression than from any other disease affecting mankind" (LaHaye, 1974, p. 16).
Life is difficult. Among work, relationships, and crises, many claim depression. But what differentiates the depression of a bad grade on a test from the depression caused by the death of a loved one? People are so quick to throw around this word that it has lost its meaning in contemporary society and has become less recognized as the serious and prevalent disorder that it is. I have watched a close family member suffer at the hand of this terrible illness. I have witnessed the depths to which it will drag its hostage and the devastation it will inflict upon a life. If this disease of the mind is so common, why do we shun it? The solution is clear: Through increased awareness and understanding of depression, we can begin to bridge the gap between "normal" society and those who feel like outcasts in their world of darkness.
Clear specifications of criteria are outlined to diagnose Major Depressive Disorder. This disorder requires more symptoms exhibited than dysthymia (a mild form of depression), and the symptoms must be more persistent (not combined with periods of normal mood). The person must also experience significantly depressed mood or loss of interest in fun activities for at least two weeks (Butcher, Carson, & Mineka, 2000). "In addition, the person must experience at least four more of the following symptoms during the same period: (1) fatigue or loss of energy; (2) insomnia or hypersomnia (that is, too little or too much sleep); (3) decreased appetite and significant weight loss without dieting (or, much more rarely, their opposites); (4) psychomotor agitation or retardation (a slowdown of mental and physical activity); (5) diminished ability to think or concentrate; (6) self-denunciation to the point of claiming worthlessness or guilt out of proportion to any past indiscretions; and (7) recurrent thoughts of death or thoughts of suicide" (Butcher et al., 2000, p. 216).
The symptoms previously mentioned must be present all day and almost every day for two weeks for a diagnosis to be justifiable (Butcher et al., 2000). The Diagnostic Criteria for 296.3x Major Depressive Disorder, Recurrent, as specified by the American Psychiatric Association (1994) in the DSM-IV are the following:
- Presence of two or more Major Depressive Episodes.
- The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
- There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. (p. 345)
Similarly, substance-induced mood disorder and mood disorder due to a general medical condition are not classified as Major Depressive Disorder. An episode of this disorder ends when the criteria are not met for two months (American Psychiatric Association, 1994).
Depression is not just 21st century language. This mental illness has been identified for most of known time. In describing depression, LaHaye (1974) wrote, "There are few psychiatric syndromes whose clinical descriptions are so constant through successive eras of history" (p. 18). In the Bible, Job suffered from a serious state of depression after losing his possessions and his family (Job 7:3-11). Many years later, Hippocrates, a Greek physician and philosopher categorized depression, referring to one temperament as melancholia. He proposed that it was caused by black blood in the patient's veins. In the 2nd century, a physician named Aretaeus used the words sad and dismayed to refer to depression, saying that these types of people become thin, agitated, and sleepless. In describing melancholia in a religious context, Plutarch said that depression was caused by sin in a person's life. According to him, that person is hated by the gods and is plagued by a life of sin (LaHaye, 1974). Hundreds of years later, depression was still making headlines in the history books. "In his 1916 paper 'Mourning and Melancholia' Freud tried to distinguish the sadness or the grief we all experience over bereavement from what he called melancholia" (White, 1982, p. 105).
There are many different types of depression. Major Depressive Disorder is called unipolar depression because there is no mania associated with it (Womens Health Channel, 2003). It is difficult to differentiate Major Depressive Disorder from other depressive disorders because there is much overlap of symptoms. The subtypes of depression are based on symptom patterns and the thought that there may be different cause and effect treatments for different subtypes (Butcher et al., 2000). There are three types of depressive episodes: single (occurs once and not again), recurrent (occurs more than once in two months), and seasonal (occurs in a pattern of certain months, usually during the fall and winter) (Womens Health Channel, 2003).
Because Major Depressive Disorder may be a single or recurrent episode, it shows that depressive episodes are commonly time-limited (Butcher et al., 2000). There is a great difference between people who experience recurrent depression and those with only a single episode. "Those with some form of recurrent depression show not only greater severity in terms of number and frequency of symptoms, but also many more suicide attempts, a much higher proportion with a family history of depression, more work and social impairment, and higher divorce rates. They also have more impaired social functioning between episodes" (Butcher et al., 2000, p. 218). Regarding the recurrence of depression, 80 to 90 percent of patients with a major depressive episode will experience another episode within two years of the first one (U.S. Public Health Service, 2003). The chance of recurring episodes depends on the severity of the initial episode, where the severity is described as mild, moderate, severe without psychotic features, or severe with psychotic features (American Psychiatric Association, 1994).
Also, regarding the recurrence of a major depressive episode, evidence shows that the number of prior episodes has a strong influence. On the other hand, a person has a smaller chance of recurrence the longer they have been symptom-free. Though previously believed that a person is normal between episodes of depression, data have shown that major depressive episodes may leave scars, which may make that person vulnerable for future recurrences. These scars are more likely in the youth, those with several past episodes, and those with the melancholic subtype (Butcher et al., 2000).
The seasons may also contribute to the recurrence of depression. This is known as Seasonal Affective Disorder. "To meet DSM-IV criteria for recurrent major depression with a seasonal pattern, the person must have had at least two episodes of depression in the past two years occurring at the same time of the year (most commonly the fall or winter), and full remission must also have occurred at the same time of the year (most commonly the spring). In addition, the person cannot have had other nonseasonal depressive episodes in the same two-year period, and most of their lifetime depressive episodes must have been of the seasonal variety" (Butcher et al., 2000, p. 219). Data show that Seasonal Affective Disorder is more common for people living in the northern climates and in younger people (Butcher et al., 2000).
The melancholic subtype is a severe subtype of depression. To qualify for this, a person must experience the criteria for major depression and must have a loss of interest in all activities, or he must not positively react to desired events (Butcher et al., 2000). "In addition, the patient must also experience at least three of the following: (1) early morning awakenings, (2) depression being worse in the morning, (3) marked psychomotor retardation or agitation, (4) significant loss of appetite and weight, (5) inappropriate or excessive guilt, or (6) the depressed mood has a qualitative difference from the sadness experienced following a loss or during a nonmelancholic depression" (Butcher et al., 2000, p. 217). Melancholia is theoretically important because, in psychiatric literature, it is very closely linked to the concept of endogenous causation, which is the idea that certain depressions are caused from within and are not related to stressful events in a person's life (Butcher et al., 2000). This may explain why melancholia is more prevalent among older people than younger people (U.S. Public Health Service, 2003).
Another subtype includes psychotic features. Severe Major Depressive Episode with Psychotic Features includes psychotic symptoms, such as loss of contact with reality and delusions or hallucinations. The hallucinations experienced are usually mood-congruent, meaning that their negative content correlates with the tone of depression (ex: inadequacy, guilt, disease, death, etc.). In a depressive episode, one would not have delusions of saving the world (Butcher et al., 2000). Those with psychotic features have a greater chance of relapsing, with more psychotic features evident in their episode (Butcher et al., 2000).
A person may be diagnosed with the subtype of double depression if their major depression coexists with dysthymia. This means that they are mildly depressed over a long period of time with sporadic periods of major depressive symptoms (Butcher et al., 2000). "Among clinical samples of dysthymics, the experience of double depression appears to be common, although it may be much less common in dysthymics who never seek treatment" (Butcher et al., 2000, p. 218). Of these double depressives, nearly double recover from their episodes of major depression, though less than half may also recover from dysthymia (Butcher et al., 2000).
The onset of depression usually occurs between ages 24 and 44, with the highest incidence rate among the middle-aged (Womens Health Channel, 2003). Research shows that this age of onset for Major Depressive Disorder is decreasing for people born more recently (American Psychiatric Association, 1994). Also, twice as many women suffer from depression as men. Men, it is believed, tend to look to alcohol instead of becoming depressed (White, 1982).
One reason that depression cannot remain hidden for long is because its symptoms are numerous and not easily hidden. "The foremost symptoms of depression are loss of interest, loss of energy, and an inability to experience pleasure" (Womens Health Channel, 2003, p. 2). Physical symptoms include erratic sleep behavior (most common); apathy and legarthy; loss of appetite; loss of sex drive; unkept appearance; and physical ailments. Emotional symptoms include loss of affection; sadness; frequent crying; hostility; irritability; anxiety; fear; worry; and hopelessness (LaHaye, 1974). It is said that depression makes people more aware of their inner sensations and less aware of external events (Ostow, 1970). This yields a very selfish demeanor. "The depressed individual is obsessed by self-criticism both voiced and unvoiced. He abuses and degrades himself. It is as though his conscience had gained control over his voice and over his body and mounted an attack upon him" (Ostow, 1970, p. 42). Perhaps as a result of this, a depressed person experiences constant delusions of guilt and self-depreciation (Ostow, 1970).
Depressive symptoms usually develop two or three weeks before a major depressive episode. Untreated depressive episodes last about eight months, whereas treated episodes last from six weeks to three months. Because depression is a disease that comes and goes, depressed people may experience one to two years of mental health without symptoms between episodes (Womens Health Channel, 2003).
A major effect of depression is insomnia. Insomnia plagues 80 percent of depressed people. People with insomnia are even said to be four times as likely to develop depression (Womens Health Channel, 2003). Abnormal sleep patterns were also found in depressed people. This was caused by improper timing of REM sleep that caused depressed people to get a lesser amount of deep sleep (Butcher et al., 2000). "Depressed patients, especially those with melancholic features, show a variety of sleep problems, ranging from early morning awakening, periodic awakening during the night (poor sleep maintenance), and, for some, difficulty falling asleep" (Butcher et al., 2000, p. 227).
The effects of depression are far-reaching. "A recent study…found unipolar major depression to be the leading cause of disability in the United States and worldwide" (National Institute of Mental Health, 2003, p. 1). In couples experiencing marital problems, one-half to one-third had a spouse with clinical depression. It must also be considered that stressful life events are the result of a depressed state. Similarly, with regards to stress, a depressed person's negative outlook on life may cause stress in their everyday situations. Consequently, depressed people have smaller and less supportive social networks (Butcher et al., 2000). This is probably caused by the depression and interpersonal problems. "…the ultimate result is probably a downwardly spiraling relationship from which others finally withdraw, making the depressed person feel worse" (Butcher et al., 2000, p. 242).
The anger experienced with depression is often toward a loved one, such as a spouse. This anger causes them to hate their partner with thoughts of murder, while loving them at the same time. In this case, a dependent personality would never seriously contemplate killing their loved one because they couldn't fathom living without that person (Ostow, 1970). Major Depressive Disorder also magnifies existing medical conditions. Up to 20 to 25 percent of these people will develop Major Depressive Disorder during the course of their illness. Also, "The management of the general medical condition is more complex and the prognosis is less favorable if Major Depressive Disorder is present" (American Psychiatric Association, 1994, p. 341). A pseudo-antidepressant is called "acting out," which uses temporary gratifications in the external world to subside negative depressive feelings. Acting out can be through gambling, spending money, increased sexual activity, prostitution, homosexuality, mysticism, gang behavior among adolescents, clinging, etc. (Ostow, 1970). None of these things helps the person in the long run, and their depression seems to become more hopeless.
Major Depressive Disorder has high mortality. Many deaths are correlated with it, including suicide (15 percent), age (over 55), and first year nursing home residents (American Psychiatric Association, 1994). Suicide is one of the most serious effects of depression (Gilbert, 1992). More than half of the people who commit suicide are depressed (LaHaye, 1974). Similarly, 60 percent of depressed people are disturbed with thoughts of suicide, and 15 percent of these actually carry out the act (Womens Health Channel, 2003).
Views of the causes of Major Depressive Disorder have changed over the decades. According to the Womens Health Channel's (2003) website, Major Depressive Disorder is caused by a combination of brain chemistry ("chemical imbalance"), family history, and psychosocial environment. "Depression is more common in people who have a history of trauma, sexual abuse, physical abuse, physical disability, bereavement at a young age, alcoholism, and insufficient family structure" (Womens Health Channel, 2003, p. 2).
The discussion of genetics as a causal factor of depression has been debated for decades, and evidence appears to support the hereditary contribution as a causal factor (Butcher et al., 2000). First-degree biological relatives of persons with Major Depressive Disorder are one-point-five to three times more likely to have this disorder (American Psychiatric Association, 1994). A person is 27 percent likely to inherit a mood disorder from one parent and twice as likely if both parents are affected (Womens Health Channel, 2003). Depression seems to be common in certain families, and suicide has an even greater correlation to family history. Of course, the generational instances of suicide may largely be communicated by example (Ostow, 1970). Similarly, Butcher et al. (2000) stated that mood disorders are more likely to occur in blood relatives of someone with a disorder. Some studies show that this is especially likely for melancholic and endogenous depression. This, however, is not solid evidence of genetic causation (Butcher et al., 2000). White (1982) holds a different view that genes aren't necessarily said to cause mental illness, but that they make someone vulnerable to developing one. Researchers call this genetic loading.
In another causal viewpoint, psychiatrist Aaron Beck hypothesized that depression is gradually formed from cognitive symptoms of depression, such as negative thoughts of oneself. These symptoms were previously thought to be signs of depression, but Beck hypothesized that these caused depression (Butcher et al., 2000). Beck's theory includes depressogenic schemas or dysfunctional beliefs, which are irrational and negative thoughts about oneself. These are thought to develop in childhood from experiences with peers and important people in one's life. When stressors are added to these dysfunctional beliefs, they are said to create a pattern of negative automatic thoughts, which occur just beyond the realm of awareness and involve pessimistic predictions (Butcher et al., 2000). "These pessimistic predictions tend to center on the three themes of what Beck calls the negative cognitive triad: (1) negative thoughts about the self ('I'm ugly'; 'I'm worthless'; 'I'm a failure'); (2) negative thoughts about one's experiences and the surrounding world ('No one loves me'; 'People treat me badly'); and (3) negative thoughts about one's future ('It's hopeless because things will always be this way') (Butcher et al., 2000, p. 235). In the subtypes of depression studied to date, Beck's description of negative thinking still applies. According to Butcher et al. (2000), Beck's theory "has generated a very effective form of treatment for depression known as cognitive therapy" (p. 236).
Beck also proposed two personality types who may be more vulnerable to depression when negative life events occur. One is "high on sociotropy," which is interpersonally dependent and sensitive to interpersonal losses or rejections. The other is "high on autonomy," which is achievement-oriented and self critical and is sensitive to achievement failures. These personality types are similar to the ones recognized by psychodynamic theorists (Butcher et al., 2000). In an opposing view, the Womens Health Channel's (2003) website stated that no evidence has been found that depression affects certain personality types, although a person's temperament and perception of self may predispose someone to depression.
Behavioral theories state that depression is caused by a loss of sources of positive reinforcement, often caused by the loss of a loved one. "Perhaps the most important contribution of the psychodynamic approaches to depression has been to note the importance of loss (both real and symbolic or imagined) to the onset of depression and to note the striking similarities between the symptoms of mourning and the symptoms of depression" (Butcher et al., 2000, p. 233). Therefore, people without social support are more likely to become depressed (Butcher et al., 2000). The loss of a spouse is the greatest cause of depression among adults (Womens Health Channel, 2003). Similarly, stressful life events as a causal factor have been studied more in regards to unipolar depression than for any other disorder (Butcher et al., 2000). In the opinion of Gilbert (1992), "…the concept of stress is equally worrying. Stress somehow makes mental disorder more acceptable. It is less alarmist than mental or emotional disorder. We feel better if we diagnose someone as suffering stress rather than major depressive disorder or dysthymia" (pp. 62-63).
The amount of time that an episode of depression goes untreated is about six months (Butcher et al., 2000). However, episodes of untreated depression become more frequent and severe over time. Research shows that depression often co-exists. In these cases, each illness must be diagnosed and treated separately. Similarly, depression often co-occurs with physical illnesses. In these cases, however, it usually goes unrecognized and untreated (National Institute of Mental Health, 2003). Psychotherapy's goal is to change a person's self-perception and behavior. For example, in cognitive behavioral therapy, the patient learns to cope with the stress that once caused the depression (Womens Health Channel, 2003). "The goal of cognitive behavioral therapy is to help the patient effect a change in their state of mind by teaching them how to look at life from a positive perspective and how to reward themselves for experiencing pleasure and accomplishment" (Womens Health Channel, 2003, p. 7).
The most common treatment for depression is prescription antidepressant medication (Womens Health Channel, 2003). Drug treatment is best used to subside the patient's distress so that psychoanalysis is more possible. According to Ostow (1970), antidepressant drugs are not necessarily the ideal solution to depression, and 15 to 20 percent of patients do not respond to drug therapy. When the patient is responding to the drug, it can only be withdrawn if the patient does not begin to relapse when the does is lessened. Most of the time, drugs are continued for years (Ostow, 1970). The effects of antidepressants, however, may take one to eight weeks to show (Womens Health Channel, 2003).
Before drugs were used in the treatment of depression, electric shock therapy was administered. This sends an electric shock to the brain, which causes temporary amnesia. This therapy is not commonly encouraged because it may cause denial in the patient during therapy (Ostow, 1970). However, Ostow (1970) also stated that "the denial made possible to the depressed patient by the shock-induced amnesia reduced the intensity of his ambivalent conflict and reduces his awareness of anger and disappointment" (p. 117). Electric shock treatment quickly and easily alleviates many symptoms of depression. The individual may even begin to live a normal life. But once the amnesia subsides, life will often begin to fall back into the former depressed state. Some dangers of electric shock treatment include brain damage, vertebrae fracture, and an intense fear of the shocks (Ostow, 1970). Because this therapy is controversial, it is presently reserved for patients with severe depression and who are in danger of harming themselves or others (Womens Health Channel, 2003).
To this point, an essential element has been left out. What about the spiritual side? Does sin or immorality play a role in the causation of depression—or any illness? In White's (1982) opinion, it can be said that all sickness is from sin because of the fall of man. The only biblical account of a mental illness is the insanity of King Nebuchadnezzar, which was the direct result of pride (i.e. sin) (White, 1982). Because depression is an intangible mental illness, is it a medical problem, or does demon possession play a role? The Bible seems to know the difference. In the Bible text, we know that both demon possession and mental illness existed because they are both separately referred to (White, 1982). Therefore, not all mental illness is the result of demonic possession. However, many Christian psychiatrists and psychologists believe that all mental and physical sickness in the Bible was a result of demonic activity or human sin. White (1982) stated, "My personal conviction is that our general vulnerability to poor mental health began at the dawn of human history and must not be seen as arising always as a consequence of personal sin or of demonic power. Mental health is like physical health. We are all vulnerable to its loss" (p. 25).
This spiritual side of therapy is often neglected by therapists. LaHaye (1974) stated, "Unless therapy includes a remedy for [man's] spiritual nature, it will offer only minimal or temporary results" (p. 71). Every human has a spiritual instinct, a void in their heart that can only be filled by God. Man searches to fill that void with things of this world but does not find peace until he finds God. "The most miserable or depressed people are not conscious of the fact that their misery emanates from the God-vacuum within them. This spiritual deficiency or God-void makes them vulnerable to a variety of mental, emotional and physical maladies or disorders" (LaHaye, 1974, p. 79). Many Christians who are depressed feel like they have let God down, and they experience feelings of guilt (White, 1982). But man will never be truly happy if his spirit is not filled with God. Temporary happiness may occur, but lasting happiness is impossible without God (LaHaye, 1974).
Based on all of the facts previously listed, there is no definite cause or set of causes for Major Depressive Disorder. All is relative, and all depends on factors that vary from person to person. But the fact remains that this devastating mood disorder is one that affects all areas of life. The causes, effects, and treatments are each so complex that no easy answer can be attained for a hopeless patient or a desperate therapist. But, as a final note of abundant grace, we know that there is always hope through God. When it seems that the whole world is against us and there is no where to turn, Jesus is our "constant." He is our hope. He is our guiding light. He can pull us out of our despair and wipe away the tears of our heart…if only we will allow him. There is no guarantee of mental, physical, or emotional healing, but there is a guarantee of spiritual rebirth and renewal. And in the end, that's all that matters.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV) (4th ed.). Washington, DC: Author.
Arieti, S., & Bemporad, J. (1978). Severe and mild depression. New York: Basic Books, Inc.
Butcher, J. N., Carson, R. C., & Mineka, S. (2000). Abnormal psychology and modern life. Boston: Allyn and Bacon.
Gilbert, P. (1992). Depression: The evolution of powerlessness. New York: The Guilford Press.
LaHaye, T. (1974). How to win over depression. Grand Rapids: Zondervan Publishing House.
National Institute of Mental Health. (2003, November 17). Depression research. Available http://www.nimh.nih.gov/publicat/depresfact.htm.
Ostow, M. (1970). The psychology of melancholy. New York: Harper & Row.
U.S. Public Health Service. (2003, November 17). Mood disorders. Available http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec3.html.
White, J. (1982). The masks of melancholy. Downers Grove, IL: InterVarsity Press.
Womens Health Channel. (2003, November 17). Major depressive disorder. Available http://www.womenshealthchannel.com/depression/index.shtml.