depression

Depression Learn how the brain works, and how to recognize the symptoms of depression.

1. 1. The act of depressing.
   2. The condition of being depressed.
2. An area that is sunk below its surroundings; a hollow.
3. The condition of feeling sad or despondent.
4. Psychology. A psychiatric disorder characterized by an inability to concentrate, insomnia, loss of appetite, anhedonia, feelings of extreme sadness, guilt, helplessness and hopelessness, and thoughts of death. Also called clinical depression.
5. 1. A reduction in activity or force.
   2. A reduction in physiological vigor or activity: a depression in respiration.
   3. A lowering in amount, degree, or position.
6. Economics.
   1. A period of drastic decline in a national or international economy, characterized by decreasing business activity, falling prices, and unemployment.
   2. Depression The worldwide economic depression from the late 1920s through the 1930s. In the United States, it began with the stock market crash in October, 1929.
7. Meteorology. A region of low barometric pressure.
8. The angular distance below the horizontal plane through the point of observation.
9. Astronomy. The angular distance of a celestial body below the horizon.

Definition

When discussing depression as a symptom, a feeling of hopelessness is the most often described sensation. Depression is a common psychiatric disorder in the modern world and a growing cause of concern for health agencies worldwide due to the high social and economic costs involved. Symptoms of depression, like the disorder itself, vary in degree of severity, and contribute to mild to severe mood disturbances. Mood disturbances may range from a sudden transitory decrease in motivation and concentration to gloomy moods and irritation, or to severe, chronic prostration.

With treatment, more than 80% of people with depression respond favorably to medications, and the feeling of hopelessness subsides. With treatment, most people are able to resume their normal work and social activities.

Depression may occur at almost any stage of life, from childhood to middle or old age, as a result of a number of different factors that lead to chemical changes in the brain. Traumatic experiences, chronic stress, emotional loss, dysfunctional interpersonal relationships, social isolation, biological changes, aging, and inherited predisposition are common triggers for the symptoms of depression. Depression is classified according to the symptoms displayed and patterns of occurrence. Types of depression include major depressive disorder, bipolar depressive disorder, psychotic depressive disorder, postpartum depression, premenstrual dysphoric disorder, and seasonal disorder. Additional types of depression are included under the label of atypical depressive disorder. Many symptoms overlap among the types of depression, and not all people with depression experience all the symptoms associated with their particular type of the disorder.

Description

Symptoms of a depressive disorder include at least five of the following changes in the individual's previous characteristics: loss of motivation and inability to feel pleasure; deep chronic sadness or distress; changes in sleep patterns; lack of physical energy (apathy); feelings of hopelessness and worthlessness; difficulty with concentration; overeating or loss of appetite; withdrawal from interpersonal interactions or avoidance of others; death wishes, or belief in his/her own premature death. In children, the first signs of depression may be irritation and loss of concentration, apathy and distractibility during classes, and social withdrawal. Some adults initially complain of constant fatigue, even after long hours of sleep, digestive disorders, headaches, anxiety, recurrent memory lapses, and insomnia or excessive sleeping. An episode of major depression may be preceded by a period of dysthymia, a mild but persistent low mood state, usually accompanied by diminished sexual drive, decreased affective response, and loss of interest in normal social activities and hobbies.

Most individuals with depression have difficulty in dealing with the challenges of daily life, and even minor obstacles or difficulties may trigger exaggerated emotional responses. Frustrating situations are frequently met with feelings of despair, dejection, resentment, and worthlessness, with people easily desisting from their goals. People with depression may try to avoid social situations and interpersonal interactions. Some people with depression overeat, while others show a sharp loss of appetite (anorexia). In some individuals, medical treatments for some other existing illness may also cause depression as an adverse reaction. For instance, antihypertensive drugs, steroids, muscle relaxants, anticancer drugs, and opioids, as well as extensive surgery such as a coronary bypass, may lead to depression. Cancer and other degenerative diseases, chronic painful conditions, metabolic diseases or hormonal changes during adolescence, or after childbirth, menopause, or old age may be potential triggers for depression. When the first onset of depression occurs after the age of 60, there is a greater possibility that the causative factor is a cerebrovascular (blood vessels in the brain) degeneration.

Molecular genetics research has recently shown that mutations in a gene coding for a protein that transports serotonin (a neurotransmitter) to neurons may determine how an individual will cope with stressful situations. A two-decade study involving 847 people of both sexes has shown that those who inherited two copies of the long version of the gene 5-HTT have a 17% risk of suffering a major depressive episode due to exposure to four or more identified stressful situations in their lives, whereas those with one long and one short version of the gene had the risk increased to 33%. The study has also shown that individuals with two short copies of the gene have a 43% probability of a major depressive episode when exposed to four or more stressful life events. The shorter version of the gene 5-HTT does not directly causes depression, but offers less protection against the harmful effects of traumatic or stressful situations to the brain. Studies of population genetics have also shown that about 50% of the world's Caucasian population carry one short and one long version of 5-HTT genes.

Depressive episodes may be associated with additional psychiatric disorders. Neurotic depression is often triggered by one or more adverse life events or traumatic experiences that have historically caused anxiety in the life of the person experiencing depression. For example, loss of social or economical status, chronic failure in living up to the expectations of parents, teachers, or bosses, death of a close relation, work-related competitive pressures, and other stressful situations such as accidents, urban violence, wars, and catastrophic events may lead to a depressive episode. Conversely, anxiety disorders such as panic syndrome, phobias, generalized anxiety, and post-traumatic stress disorder may trigger a major depressive crisis. Psychotic depressive disorders are likely to be associated with other psychiatric diseases or caused by them. Eating disorders such as bulimia, anorexia nervosa, and binge-eating disorder are generally accompanied by depression or may be caused by an existing depressive state. Neurodegenerative diseases such as Alzheimer's, Huntington's, and Parkinson's diseases frequently have depression among their symptoms.

Dysthymia is a mild but chronic depressed state, characterized by melancholic moods, low motivation, poor affective responsiveness, and a tendency for self isolation. A dysthymic state lasting two years or longer is a risk factor for the onset of a major depressive episode. However, many dysthymic individuals experience a chronic low mood state throughout their daily lives. Dysthymia is a frequent occurrence in individuals involved in chronic dysfunctional marriages or unsatisfying work conditions. Such chronic stressful situations alter the brain's neurochemistry, thus the opportunity arises for symptoms of depression to develop.

Psychotic depression is a particularly serious illness and possesses biological and cognitive (thought) components. Psychotic depression involves disturbances in brain neurochemistry as a consequence of either a congenital (from birth) condition or due to prolonged exposure to stress or abuse during early childhood. Prolonged exposure to severe stress or abuse in the first decade of life induces both neurochemical and structural permanent changes in the developing brain with a direct impact on emotional aspects of personality. Normal patterns of perception and reaction give way to flawed mechanisms in order for a person to cope with chronic fear, abuse, and danger. Perception becomes fear-oriented and conditioned to constantly scan the environment for danger, with the flight-or-fight impulse underlying the individual's reactions. Delusions, misinterpretation of interpersonal signals, and a pervading feeling of worthlessness may impair the individual's ability to deal with even minor frustrations or obstacles, precipitating deep and prolonged episodes of depression, often with a high risk of suicide. Hallucinations may also occur, such as hearing voices or experiencing visions, as part of depression with psychosis.

A major depressive disorder (MDD) or clinical depression may consist of a single episode of severe depression requiring treatment or constitute the initial sign of a more complex disorder such as bipolar disorder. MDD may last for several months or even years if untreated and is associated with a high risk of suicide. In bipolar disorder, manic (hyper-excited and busy) periods alternate with deep depressive episodes, and are characterized by abnormal euphoria (an exaggerated feeling of happiness and well-being) and reckless behavior, followed by deep distress and prostration, often requiring hospitalization.

Major episodes of depression may last for one or more years if not treated, leading to a deep physical and emotional prostration. The person with major depression often moves very slowly and reports a sensation of heaviness in the arms and legs, with simple walking requiring an overwhelming effort. Personal hygiene is neglected and the person often desires to stay secluded or in bed for days or weeks. Suicidal thoughts may frequently occupy the mind or become recurrent patterns of thinking. Painful or unsettling memories are often recalled, and contribute to feelings of helplessness.

Atypical depression causes a cyclic behavior, alternating periods of severe and mild depressive states, punctuated by mood swings, hypersensitivity, oversleeping, overeating, with or without intermittent panic attacks. This depressive disorder is more common in women, with the onset usually occurring during adolescence.

Premenstrual dysphoric disorder (PDD) is not premenstrual stress. It is a more severe mood disorder that can cause deep depression or episodes of heightened irritation and aggressiveness, starting one or two weeks before menstruation and usually persisting during the entire period. Premenstrual dysphoric disorder is associated with abnormal changes in levels of hormones that affect brain neurochemistry.

Seasonal affective disorder (SAD) is caused by disturbances in the circadian cycle, a mechanism that controls conversion of serotonin into melatonin in the evening and mid-afternoon, and the conversion of melatonin into serotonin during daytime. Serotonin is the neurotransmitter responsible for sensations of satiety and emotional stability, which is converted at nighttime into melatonin, the hormone that regulates sleep and other functions. Some people are especially susceptible to the decreased exposure to daylight during long winter months and become depressed and irritable. Overeating and oversleeping during the winter season are common signs of seasonal affective disorder, along with irritation and depressed moods. However, as the amount of light increases during the spring and summer seasons, the symptoms disappear.

Postpartum depression is a severe and long-lasting depressive state also associated with abnormal changes in hormone levels affecting brain neurochemistry. If untreated, postpartum depression may last for months or even years, and is highly disruptive to family and maternal-child relations.

Without treatment, the risk of suicide as a consequence of depression should not be underestimated. Suicide accounts for approximately 15% of deaths among people with significant depression, and half of all suicide attempts in the United States are associated with depression. Persistent and recurrent depressive episodes are important contributors to other diseases alike such as myocardial infarction, hypertension, and other cardiovascular disorders.

Resources

BOOKS

Klein, Donald F., MD. Understanding Depression: A Complete Guide to Its Diagnosis and Treatment. New York: Oxford Press, 1995.

Solomon, Andrew. The Noonday Demon: An Atlas of Depression. New York: Scribners, 2002.

PERIODICALS

Manji, H. K., W. C. Drevets, and D. S. Charney. "The Cellular Neurobiology of Depression." Nature Medicine (May 2001) 7: 541–546.

Teicher, Martin H. "Wounds That Won't Heal—The Neurobiology of Child Abuse." Scientific American (March 2002): 68–75.

OTHER

National Institute of Mental Health. Depression. February 12, 2004 (March 31, 2004). http://www.nimh.nih.gov/publicat/depression.cfm#ptdep1.

ORGANIZATIONS

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (800) 615-NIMH (6464); Fax: (301) 443-4279. nimhinfo@nih.gov. http://www.nimh.nih.gov.

Sandra Galeotti

Key Terms: Cognitive-behavioral therapy, Depression screen.

Description

Everybody feels sad sometimes, but to be clinically depressed is not just a matter of feeling sad. A patient with cancer is diagnosed as having major depression only if certain symptoms, such as loss of pleasure or thoughts of death, are present for at least two weeks. Only a healthcare professional can accurately determine whether a patient is depressed or is simply upset because of the disease.

A Note on Depression and Children With Cancer

Few children with cancer experience depression. For many children survivors of cancer, the experience of having had cancer makes them deeper, more understanding human beings later in adulthood and old age. However, some children with cancer do experience depression, sleep problems, and relationship problems. Depression appearing in a child who has cancer should be treated by a healthcare professional.

The symptoms of depression in children are somewhat different from those in adults. The physician should be notified of a sad mood (or, in children less than six years of age, a facial expression that appears to express sadness) that continues for at least two weeks and is accompanied by at least four of the following: (a) appetite changes, (b) sleep problems or excessive sleep, (c) excessive activity or inactivity, (d) loss of pleasure, (e) not caring about anything, (f) fatigue, (g) being overly critical of himself or herself, (h) feeling worthless or guilty for no apparent reason, (i) inability to concentrate, and (j) thoughts of death.

Are Most People Who Have Cancer Depressed?

Most people who have cancer are not depressed. Depression is found in cancer patients about as frequently as in patients hospitalized for major, noncancer illnesses such as heart disease. However, depression is more often present in people who have cancer than in the general population. Approximately one out of eight people with cancer are depressed. Among hospitalized people with cancer, roughly one in four is depressed.

Depression and Embarrassment

Doctors and nurses can do a great deal to help a depressed person feel better. Being embarrassed can get in the way of the patient's getting help. While depression is a disease that happens to a minority of cancer patients, it does appear in a sizable number of these patients. Doctors and nurses are trained to deal with depression in cancer patients. If one out of eight people with cancer are depressed, it is no surprise to healthcare professionals that some patients require treatment for depression. It is not "bothering" a good health care professional to let them know that the patient is experiencing some symptoms that may signal depression. Competent doctors and nurses will not think less of a patient who is depressed. Rather, they will respect the patient who acknowledges the willingness to seek and accept treatment for depression. Cooperative patients are not those who hide depression but those who deal with depression when it appears. Dealing honestly and with the aid of doctors and allied healthcare professionals is the right way to address any cancer-related symptom.

How Does Depression Affect Someone Who Has Cancer?

Depression is not something that can be pointed to, as one would point to a runny nose or an earache. That does not mean it is not real, nor does it mean the depression does not have a major effect on the cancer patient. The fact is that depression may not only affect what patients can do and how they feel, depression may also affect how well they function and how long they live.

A study of patients with acute leukemia who were receiving bone marrow transplantation found that those who were not depressed lived longer. A study of breast cancer patients showed that depression can be treated successfully and life extended. In this study, women with metastatic breast cancer who joined a support group lived twice as long as matched patients who did not join a support group. In light of these types of studies it would be incorrect to assume that depressed cancer patients who work with their doctors and nurses to treat their depression do not live as long as patients without depression.

Untreated depression or inadequately treated depression may slow recovery time. A study of depressed colorectal cancer patients found they were not able to function as well six months after surgery as patients who were not depressed. Another study found that breast cancer patients who were more anxious and depressed felt more pain than those who were not. Other studies have also shown that depression affects how people function and cope with illness.

Causes

It is certainly understandable that someone with a serious illness feels sad. Many cancer patients are confronted with difficulties. These may include having to take medications, dealing with the side effects of these medications, undergoing operations, submitting to other medical procedures, and generally taking time away from other things they would prefer to do. In addition, many patients feel a sense of loss. They may feel a loss of good health; there may be a loss of part of the body, such as a segment of a breast; there may be a loss of the ability to do certain tasks. There may also be financial strains. Any such things are difficult for most people to deal with. It takes time and effort, and sometimes medical intervention, for people to deal with such loss and gradually get their lives back on track.

If patients are in pain it is extremely important that the pain be adequately treated. Pain is often under-treated. When pain is not treated appropriately, patients may be more likely to develop depression.

Patients with cancer of the pancreas are particularly likely to become depressed. In addition, patients with breast, colon, gynecologic, oropharyngeal, and stomach cancer are more likely to experience depression than patients with other types of cancers. No one knows why depression is more likely to be associated with these cancers.

Approximately one out of every four patients with depression associated with cancer already was depressed at the time of diagnosis. In contrast, approximately three out of four develop the depression after the diagnosis has been made.

Risk Factors for Depression Among Cancer Patients

Anyone can become depressed, and this includes people with cancer and people who are perfectly healthy. Often, there is no way of predicting who will develop major depression. However, some groups of cancer patients are more likely to develop depression than are others. This include patients who:

• are younger
• have a personal or family history of depression or other mental health problems
• have a personal or family history of substance abuse
• have body image problems
• are hospitalized
• are experiencing unrelieved cancer-related symptoms, such as pain
• have advanced or relapsed cancer, or have experienced a treatment failure
• have been diagnosed with stroke or with Parkinson's disease

In addition, some patients are receiving medicines that may cause depression as a side effect. Among these medicines are certain anticancer drugs, antihistamines, blood pressure medicines, anti-Parkinson's disease medicines, medications for convulsions, sedatives, steroids, stimulants, and tranquilizers.

Signs and Symptoms

A patient with cancer is diagnosed as having major depression only if certain symptoms are present for at least two weeks. Among these symptoms are:(a) loss of pleasure or interest in activities, (b) major weight loss or weight gain not associated with dieting, (c) serious sleep problems, (d) loss of energy, (e) fatigue, (f) feeling worthless, (g) feeling guilty without adequate reason, (h) problems concentrating, (i) indecisiveness, (j) thoughts of death or suicide. Symptoms such as sleep problems, fatigue, and weight loss may, however, affect cancer patients who are not depressed in the slightest. So, the diagnosis must be made by a healthcare professional.

Often depression appears gradually. At first, the patient seems no more than sad. At times, the person who is in a very early stage of depression brightens up. For many people things never get worse than this and true depression never touches them. However, other people progress to where negative thoughts have a grip upon them.

Gradually, some of the neurotransmitters in the nervous system may stop working in the most healthy way. Neurotransmitters are the chemicals released by nerves to communicate with other nerves. Once a patient's neurotransmitters are affected, the depression is definitely not simply happening in the patient's mind. The way the body uses actual chemicals is being altered by the depressive disease.

Precisely how the depression shows itself may differ from patient to patient. For example, some patients start to respond to little setbacks as though these are catastrophes. Other patients start making big assumptions, usually in negative directions; for example, they may assume their current therapy will not help them, even although there is good medical evidence that it probably will. For yet another example, they may blame themselves for having cancer, or irrationally see the cancer as a punishment visited upon them for something they have done. Patients may try to be too perfect and repeatedly fail. They may think other people have negative feelings about them, or they may focus upon the negative portions of situations. One danger is that the looming depression may encourage patients to push away and alienate those health professionals, friends, and family members who are trying to be helpful. For a final example, a depressed patient may deny the seriousness of the cancer, saying something like, "The tumor is small so I don't really need to be careful about taking my medicines."

Some patients experience a milder form of depression, called dysthymia. Symptoms of dysthymia include annoyance, feelings of sadness, irritability, loss of pleasure, and self-criticism. The patient with dysthymia may develop aches and pains, express excessive guilt, and distance themselves from loved ones. Dysthymia may be almost unnoticeable; however, many patients with dysthymia are unable to function quite as well as they can when they are healthy.

Depression Screens

The attending doctor or nurse may request that the patient complete a depression screen. This screen is nothing more than a page or two of questions about how the patient is feeling. The patient's responses give healthcare professionals a picture of whether or not depression may be present.

Prevention

It is important for patients to have an idea of the psychological and social stressors they may have to address because of the cancer. Knowing in advance that something may be a problem is a good way of making sure that it is not quite as stressful once it does appear as it otherwise would be. Patients, their families, and close friends should be able to recognize the most important signs and symptoms of depression and should know which healthcare professional to call should depression appear. However, no one except a professional is capable of accurately diagnosing depression. It is a good idea to try to develop an honest relationship with a healthcare professional you trust. Parents of a child who has cancer may find a parent support group helpful, as there is a great deal to learn from other parents who have been through a similar situation.

Treatments

Most important is that study after study has shown that depression in cancer patients can be successfully treated. It is important to understand that this problem probably can get better. Several different approaches to treatment can be taken, and several of these approaches can be effectively combined with one another

If the patient has a doctor or nurse capable of providing sustained emotional support, that can be helpful. On the other hand, it is important for patients to realize that doctors and nurses are usually extremely busy and that it may be necessary to find someone else to provide sustained emotional support. This other person may be a trained professional, such as a social worker, a psychiatric nurse, a psychologist, or a psychiatrist. The persons who provide support may also be family members or friends. A support group may be helpful. During periods of crisis, it is beneficial to have several people who can provide support. The family member or friend who is trying to provide such support should try to listen well and sympathetically.

Cognitive Interventions

Cognitive interventions are also known as cognitive-behavioral treatment (CBT). CBT helps patients' view in a realistic way what is happening to them, where they are, and what they should or should not be doing. This type of intervention can be useful in helping patients give up negative perspectives and replace them with views that rely more upon the facts about what is going on. CBT may be practiced with a healthcare provider, or in a group with other patients and one or more providers.

Among the techniques CBT makes use of are:

• Cognitive distraction: This is the phrase used for techniques that shift the mind-frame of the patient from negative things to more positive thoughts. Music is one of the basic tools of cognitive distraction. Patients should be encouraged to listen to the type of music they like best. Headphones may be helpful if brought to diagnostic and treatment sessions and occasions when waiting is necessary. Imagery is another technique important for cognitive distraction. Imagery can help the mind shift from negative thoughts and difficult situations to helpful images. Each patient should select those images that feel right and good. For one patient this may be swimming at the beach; for another, visiting special friends; for another, walking through the forest.
• Psychoeducation: This CBT technique involves providing information to patients so patients can feel that what is going on is not entirely beyond their control. People often find it difficult to deal with the unknown, and psychoeducation attempts to remove some of what is unknown. Another important psychoeducation technique is having patients make lists of questions to ask their nurse or doctor.
• Image rehearsal: This CBT technique involves working with a healthcare professional. The patient may use image rehearsal to rehearse some activity she or he finds to be stressful. For example, image rehearsal may be used if the patient finds MRI scans or radiation treatments to be stressful.

Other CBT techniques involve relaxation techniques and the conscious decision to participate in activities the patient likes doing.

Psychotherapy

Talking to a psychologist, social worker, psychiatric nurse, psychiatrist, or other health care professional can be helpful. In addition to the cancer and problems associated with therapy, this talk therapy can help the patient address unresolved matters that were already bothersome before cancer was diagnosed.

Group Therapy

Studies have shown group therapy to be an effective approach for patients with cancer-related depression. Various approaches to group therapy may be taken. In all, however, it involves communication not only between patient and healthcare professional, but also among and between patients. Group therapy can also be helpful for loved ones of cancer patients.

Important to note is that studies have shown that cancer patients may tend to isolate themselves from friends and family. In other words, the amount of contact and communication between friends and family may be less than it had been before cancer was diagnosed. This is not a helpful trend. Research suggests that social support can have beneficial effects on a person's physical health. Group therapy can provide this type of social support to patients. In addition, group therapy may furnish a place where patients are able to learn about how to maintain contact with family and friends. It can also provide a way for patients to identify which family members and friends are not supportive.

Medication

A variety of antidepressant medications are available. Among those most frequently prescribed are psychostimulants, tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs). These medications help return the neurotransmitters to a normal, balanced function. There are at least three different psychostimulants, six different TCAs, three different SSRIs, and three different MAOIs that doctors may choose among. In addition, there are various other medications that have proven to be effective as treatment for depression. All of these drugs have been shown to work well in general; however, while one specific type of drug may be appropriate for one patient, another patient may require a completely different type of drug. Use of some of these drugs may be accompanied by side effects. Just as there are different antidepressant drugs, so are there different side effects that may appear. However, many patients have no side effects from antidepressant medications or, at most, exhibit only minor side effects. Other patients find that, although they had side effects from one drug, they experienced no side effects after they switched to another medication. Many patients find they are able to successfully combine medications and other treatment approaches, but honest communication with the physician is essestial.

The Suicidal Patient

If a patient is suicidal it is extremely important to immediately contact a healthcare professional capable of dealing with such a crisis.

Resources

Books

Spiegel, David, and Catherine Classen. Group Therapy for Cancer Patients: A Research-Based Handbook of Psychosocial Care. New York: Basic Books, 2000.

Waller, Alexander, and Nancy L. Caroline. Handbook of Palliative Care in Cancer. 2nd ed. Boston: Butterworth Heinemann, 2000.

Yarboro, Connie H., Margaret H. Frogge, and Michelle Goodman. Cancer Symptom Management. 2nd ed. Boston: Jones and Bartlett Publishers, 1999.

Periodicals

Lovejoy, Nancy C., Derek Tabor, Margherite Matteis, and Patricia Lillis. "Cancer-related Depression: Part I—Neurologic Alterations and Cognitive-Behavioral Therapy." Oncology Nursing Forum 27 (2000): 667-677.

Sheard, T., and P. Maguire. "The Effect of Psychological Interventions on Anxiety and Depression in Cancer Patients: Results of Two Meta-Analyses." British Journal of Cancer 80 (1999): 1770-1780.

—Bob Kirsch

A melancholy mood; a feeling of hopelessness or an attitude of dejection. Depression varies from mild forms, which most people experience, to very severe clinical forms that require expert medical treatment. Although depression can affect the motivation to exercise, it is generally agreed that aerobic activity can protect against and relieve depression. Aerobic exercise sustained for at least 30 minutes, five times a week, can have remarkable anti-depressant effects. The reason is unclear, but may be linked to the production of endorphins during exercise, or increased self-esteem and control.

noun

1. An area sunk below its surroundings: basin, concavity, dip, hollow, pit, sag, sink, sinkhole. See convex/concave.
2. A feeling or spell of dismally low spirits: blues, dejection, despondence, despondency, doldrums, dolefulness, downheartedness, dumps, dysphoria, funk, gloom, glumness, heavy-heartedness, melancholy, mope (used in plural), mournfulness, sadness, unhappiness. See feelings, happy/unhappy.
3. A period of decreased business activity and high unemployment: recession, slump. See rich/poor.

Definition: concavity, cavity
Antonyms: bulge, convexity, protuberance

n

Definition: low spirits; despair
Antonyms: cheerfulness, encouragement, happiness, hope, hopefulness

Definition

Depression, also known as depressive disorders or unipolar depression, is a mental illness characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep, appetite, and mental processes are a common accompaniment.

Description

Everyone experiences feelings of unhappiness and sadness occasionally. However, when these depressed feelings start to dominate everyday life without a recent loss or trauma and cause physical and mental deterioration, they become what is known as depression. Each year in the United States, depression affects an estimated 17 million people at an approximate annual direct and indirect cost of $53 billion. One in four women is likely to experience an episode of severe depression in her lifetime, with a 10–20% lifetime prevalence, compared to 5–10% for men. The average age a first depressive episode occurs is in the mid-20s, although the disorder strikes all age groups indiscriminately, from children to the elderly.

There are two main categories of depression: major depressive disorder and dysthymic disorder. Major depressive disorder is a moderate to severe episode of depression lasting two or more weeks. Individuals experiencing this major depressive episode may have trouble sleeping, lose interest in activities in which they once took pleasure, experience a change in weight, have difficulty concentrating, feel worthless and hopeless, or have a preoccupation with death or suicide. In children, major depression may appear as irritability.

While major depressive episodes may be acute (intense but short-lived), dysthymic disorder is an ongoing, chronic depression that lasts two or more years (one or more years in children) and has an average duration of 16 years. The mild to moderate depression of dysthymic disorder may rise and fall in intensity, and those afflicted with the disorder may experience some periods of normal, nondepressed mood of up to two months in length. Its onset is gradual, and dysthymic patients may not be able to pinpoint exactly when they started feeling depressed. Individuals with dysthymic disorder may experience a change in sleeping and eating patterns, low self-esteem, fatigue, trouble concentrating, and feelings of hopelessness.

Depression also can occur in bipolar disorder, an affective mental illness that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Causes & Symptoms

The causes behind depression are complex and not yet fully understood. While an imbalance of certain neurotransmitters, the chemicals in the brain that transmit messages between nerve cells, is believed to be key to depression, external factors such as upbringing (more so in dysthymia than major depression) may be as important. For example, it is speculated that, if an individual is abused and neglected throughout childhood and adolescence, a pattern of low self-esteem and negative thinking may emerge, and from that, a lifelong pattern of depression may follow. A 2003 study reported that two-thirds of patients with major depression say they also suffer from chronic pain.

Heredity seems to play a role in who develops depression. Individuals with major depression in their immediate family are up to three times more likely to have the disorder themselves. It would seem that biological and genetic factors may make certain individuals predisposed or prone to depressive disorders, but environmental circumstances may often trigger the disorder.

External stressors and significant life changes, such as chronic medical problems, death of a loved one, divorce or estrangement, miscarriage, or loss of a job also can result in a form of depression known as adjustment disorder. Although periods of adjustment disorder usually resolve themselves, occasionally they may evolve into a major depressive disorder.

Major Depressive Episode

Individuals experiencing a major depressive episode have a depressed mood and/or a diminished interest or pleasure in activities. Children experiencing a major depressive episode may appear or feel irritable, rather than depressed. In addition, five or more of the following symptoms will occur on an almost daily basis for a period of at least two weeks:

• Significant change in weight
• insomnia or hypersomnia (excessive sleep)
• psychomotor agitation or retardation
• fatigue or loss of energy
• feelings of worthlessness or inappropriate guilt
• diminished ability to think or to concentrate, or indecisiveness
• recurrent thoughts of death, or suicidal and/or suicide attempts

Dysthymic Disorder

Dysthymia commonly occurs in tandem with other psychiatric and physical conditions. Up to 70% of dysthymic patients have both dysthymic disorder and major depressive disorder, known as double depression. Substance abuse, panic disorders, personality disorders, social phobias, and other psychiatric conditions also are found in many dysthymic patients. Dysthymia is prevalent in patients with certain medical conditions, including multiple sclerosis, AIDS, hypothyroidism, chronic fatigue syndrome, Parkinson's disease, diabetes, and postcardiac transplantation. The connection between dysthymic disorder and these medical conditions is unclear, but it may be related to the way the medical condition and/or its pharmacological treatment affects neurotransmitters. Dysthymic disorder can lengthen or complicate the recovery of patients also suffering from medical conditions.

Along with an underlying feeling of depression, people with dysthymic disorder experience two or more of the following symptoms on an almost daily basis for a period for two or more years (most suffer for five years), or one year or more for children:

• under or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or trouble making decisions
• altered libido
• altered appetite
• altered motivation
• feelings of hopelessness

Diagnosis

The guidelines for diagnosis of major depressive disorder and dysthymic disorder are found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV). In addition to an interview, several clinical inventories or scales may be used to assess a patient's mental status and determine the presence of depressive symptoms. Among these tests are: the Hamilton Depression Scale (HAM-D), Child Depression Inventory (CDI), Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), and the Zung Self-Rating Scale for Depression. These tests may be administered in an outpatient or hospital setting by a general practitioner, social worker, psychiatrist, or psychologist.

Treatment

A variety of alternative medicines have proven to be helpful in treating depression. A recent report from Great Britain emphasized that more physicians should encourage alternative treatments such as behavioral and self-help programs, supervised exercise programs, and watchful waiting before subscribing antidepressant medications for mild depression. Chocolate, coffee, sugar, and alcohol can negatively affect mood and should be avoided. Essential fatty acids may reduce depression and boost mood. Expressing thoughts and feelings in a journal is therapeutic. Aromatherapy, particularly citrus fragrance, has had a positive effect on depression. Psychotherapy or counseling is an integral component of treatment because it can find and treat the cause of the depression.

Psychosocial Therapy

Psychotherapy explores a person's life to bring forth possible contributing causes of depression. During treatment, the therapist helps the patient to become aware of his or her thinking patterns and how they originated. There are several different subtypes of psychotherapy, but all have the common goal of helping the patient develop healthy problem solving and coping skills.

Cognitive-behavioral therapy assumes that the patient's faulty thinking is causing the current depression and focuses on changing thought patterns and perceptions. The therapist helps the patient identify negative or distorted thought patterns and the emotions and behavior that accompany them, and then retrains the patient to recognize the thinking and react differently to it.

Chinese Medicine and Herbals

The principle of treatment of depression involves regulating qi, reducing phlegm, calming the mind, and promoting mental resuscitation. The Chinese medicineBai Jin Wan (White Metal Pill) is used to treat depression (5 g twice daily). A practitioner may prescribe a variety of treatments—including lifestyle changes—depending on the type and severity of the depression.

There is some evidence that acupuncture is a helpful treatment for depression. One double-blind study found that patients who received acupuncture specific for depression were significantly less depressed than control patients who had either nonspecific acupuncture or no treatment.

St. John's wort (Hypericum perforatum) is the most widely used antidepressant in Germany. Many studies on the effectiveness of St. John's wort have been performed. One review of the studies determined that St. John's wort is superior to placebo and comparable to conventional antidepressants. In early 2000, well designed studies comparing the effectiveness of St. John's wort versus conventional antidepressants in treating depression were underway in the United States. Despite uncertainty concerning its effectiveness, a 2003 report said acceptance of the treatment continues to increase. A poll shoed that about 41% of 15,000 science professionals in 62 countries said they would use St. Johnís wort for mild to moderate depression. Although St. John's wort appears to be a safe alternative to conventional antidepressants, care should be taken, as the herb can interfere with the actions of some pharmaceuticals. The usual dose is 300 mg three times daily.

Orthomolecular Therapy

Orthomolecular therapy refers to therapy that strives to achieve the optimal chemical environment for the brain. The theory behind this approach is that mental disease is caused by low concentrations of specific chemicals. Linus Pauling believed that mental disease was caused by low concentrations of the B vitamins, biotin, vitamin C, or folic acid. Supplementation with vitamins B₁, B₂, and B₆ improved the symptoms of depression in geriatric patients taking tricyclic antidepressants. The amino acids tryptophan, tyrosine, and phenylalanine have been shown to have positive effects on depression, although large, controlled studies need to be carried out to confirm these findings.

S-ADENOSYL-METHIONINE. In several small studies, S-adenosyl-methionine (SAM, SAMe) was shown to be more effective than placebo and equally effective as tricyclic antidepressants in treating depression. The usual dosage is 200 mg to 400 mg twice daily. In 2003, a U.S. Department of Health and Human Services team reviewed 100 clinical trials on SAMe and concluded that it worked as well as many prescription medications without the side effects of stomach upset and decreased sexual desire.

5-HYDROXYTRYPTOPHAN. 5-hydroxytryptophan (5-HT, 5-HTP) is a precursor to serotonin. Most of the commercially available 5-HT is extracted from the plant Griffonia simplicifolia. In several small studies, treatment with 5-HT significantly improved depression in more than half of the patients. One review of these studies suggests that 5-HT has antidepressant properties, however, large studies must be performed to confirm this finding. The usual dose is 50 mg three times daily. Side effects include nausea and gastrointestinal disturbances.

Homeopathic Remedies

Homeopathic remedies can be helpful treatments for depression. A homeopathic practitioner should be consulted for dosages, but common remedies are:

• Arum metallicum for severe depression
• Ignatia for adjustment disorder
• Natrum muriaticum for depression of long duration.

Light Therapy

Light therapy is helpful in controlling the depression of seasonal affective disorder (SAD). Treatment consists of exposure to light of a high intensity and/or specific spectra for an hour per day from a light box placed on the floor or on a table. The light intensity is usually 10,000 lux which is similar to the light of a sunny day. The opposite may be used, as well, which is the use of a dawn simulator for those patients who have an overdose of light exposure and require more sleep with less light. Most persons will see an effect within three to four weeks. Side effects include headaches, eye-strain, irritability, and insomnia. A week or more in a sunny climate may improve SAD.

Allopathic Treatment

Depression usually is treated with antidepressants and/or psychosocial therapy. When used together correctly, therapy and antidepressants are a powerful treatment plan for the depressed patient.

Drugs

Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and sertraline (Zoloft), reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, poor sexual functioning, and insomnia all are possible side effects of SSRIs. A recent study shows this generation of drugs increases patients' risk of gastrointestinal bleeding.

Tricyclic antidepressants (TCAs) are less expensive than SSRIs, but have more severe side effects including persistent dry mouth, sedation, dizziness, and cardiac arrhythmias. Because of these side effects, caution is taken when prescribing TCAs to elderly patients. TCAs include amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). A 10-day supply of TCAs can be lethal if ingested all at once, so these drugs may not be a preferred treatment option for patients at risk for suicide.

Monoamine oxidase inhibitors (MAO inhibitors), such as tranylcypromine (Parnate) and phenelzine (Nardil), block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must avoid foods high in tyramine (found in aged cheeses and meats) to avoid potentially serious hypertensive side effects.

Heterocyclics include bupropion (Wellbutrin) and trazodone (Desyrel). Bupropion is prescribed to patients with a seizure disorder. Side effects include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, low blood pressure, and insomnia. Because trazodone has a sedative effect, it is useful in treating depressed patients with insomnia. Other possible side effects of trazodone include dry mouth, gastrointestinal distress, dizziness, and headache. In 2003, Well-butrin's manufacturer released a once-daily version of the drug that offered low risk of sexual side effects or weight gain.

Electroconvulsive Therapy

ECT, or electroconvulsive therapy, usually is employed after all therapy and pharmaceutical treatment options have been explored and exhausted. However, it is sometimes used early in treatment when severe depression is present and the patient refuses oral medication, or when the patient is becoming dehydrated, extremely suicidal, or psychotic.

The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under general anesthesia and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Memory loss, typically transient, has also been reported in ECT patients. ECT causes severe memory problems for months or years in one out of every 200 patients treated.

Late in 2001, a study reported on a pacemaker-like device used to treat epilepsy adapted for patients with depression. An implanted electronic device sends intermittent signals to the vagus nerve, which in turn carries the signals to the brain, connecting in areas known to regulate mood. Although still experimental at this time, early results in treating depression have been encouraging.

Expected Results

Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 80–90% of depressed patients. After each major depressive episode, the risk of recurrence climbs significantly—50% after one episode, 70% after two episodes, and 90% after three episodes. For this reason, patients need to be aware of the symptoms of recurring depression and may require long-term maintenance treatment.

Overall, recent recommendations from mental health clinicians suggest that the recovery process for patients with depression works best when mental health professionals focus on the whole person behind the disorder. In addition to prescribing medications, they also should address a patient's self-esteem, feeling of control, and determination. They emphasize that patients with depression need a sense of optimism and should be encouraged to seek the support of family members and friends.

Prevention

Patient education in the form of therapy or self-help groups is crucial for training patients with depressive disorders to recognize early symptoms of depression and to take an active part in their treatment program. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Early intervention with children with depression is effective in halting development of more severe problems.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.

Peightel, James A., Thomas L. Hardie, and David A. Baron. "Complementary/Alternative Therapies in the Treatment of Psychiatric Illnesses." In Complementary/Alternative Medicine: An Evidence Based Approach. John W. Spencer and Joseph J. Jacobs, eds. St. Louis: Mosby, 1999.

Thompson, Tracy. The Beast: A Reckoning with Depression. New York: G. P. Putnam, 1995.

Ying, Zhou Zhong and Jin Hui De. "Psychiatry and Neurology." In Clinical Manual of Chinese Herbal Medicine and Acupuncture. New York: Churchill Livingston, 1997.

Periodicals

"A Natural Mood-booster that Really Works: a Group of Noted Researchers Found that the Supplement SAMe Works as Well as Antidepressant Drugs." Natural Health (July 2003): 22.

"Antidepression 'Pacemaker' Demonstrates Long-Term Benefits." Medical Devices and Surgical Technology Week. (December 30, 2001): 34.

Deltito, Joseph, and Doris Beyer. "The Scientific, Quasi-scientific and Popular Literature on the Use of St. John's Wort in the Treatment of Depression." Journal of Affective Disorders 51 (1998): 345-351.

"FDA Approves Once-daily Supplement." Biotech Week (September 24, 2003): 6.

Head, Kathi. "Conquer Depression Without Drugs." Let's Live 68 (2000): 72+.

Jancin, Bruce. "Chronic Pain Affects 67% of Patients With Depression: 'Stunning' Finding in Primary Care Study." Internal Medicine News (September 15, 2003): 4.

Miller, Mark D. "Recognizing and Treating Depression in the Elderly." Medscape Mental Health 2, no.3 (1997). http://www.medscape.com.

Miller, Sue. "A Natural Mood Booster." Newsweek (May 5, 1997): 74-5.

"New Depression and Anxiety Treatment Goals Defined." Health and Medicine Week. (December 31, 2001): 24.

Salmans, Sandra. "More on Treatments." Depression: Questions You Have .. Answers You Need (1997): 145+.

Sansone, Randy A. and Lori A. Sansone. "Dysthymic Disorder: The Chronic Depression." American Family Physician 53, no. 8 (June 1996): 2588-96.

"St. John's Wort Healing Reputation Upheld?" Nutraceuticals International. (September 2003).

"Try Alternatives Before Using Antidepressants." GP. (September 29, 2003): 12.

Organizations

American Psychiatric Association (APA). Office of Public Affairs, 1400 K Street NW, Washington, DC 20005. (202) 682-6119. http://www.psych.org/.

American Psychological Association (APA). Office of Public Affairs, 750 First St. NE, Washington, DC 20002-4242. (202) 336-5700. http://www.apa.org/.

National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, Suite 1015, Arlington, VA 22203-3754. (800) 950-6264. http://www.nami.org.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. http://www.ndmda.org.

National Institute of Mental Health (NIMH). 5600 Fishers Lane, Rm. 7C-02, Bethesda, MD 20857. (301) 443-4513. http://www.nimh.nih.gov/.

[Article by: Belinda Rowland; Teresa G. Odle]

Depression is sometimes referred to as the common cold of mental illness. It is a debilitating disease with significant societal costs. It is, however, one of the most clearly defined and treatable of mental illnesses. Technically, the term "depression" is used to cover a variety of symptomatic conditions, all characterized by negative mood and a loss of pleasure. Together these conditions comprise a spectrum ranging from major depression to dysthymia to adjustment reactions to normal grief and sadness. At one extreme of this continuum lies major depressive disorder, a syndrome characterized by severe episodes of depressed mood accompanied by loss of sleep, appetite, concentration, energy, and hope. The depressed mood must persist for greater than two weeks in order to warrant this diagnosis. At the other end of the continuum lies the diagnosis of dysthymia, which is characterized by a lower level of mood disturbance that persists chronically; that is, involving more days than not for a period of two years or greater. Many patients complain of depressed mood but do not fit neatly into either of these two categories. These patients' symptoms are frequently best accounted for as a reaction to an acute life stressor. These reactions are typically nonpathological and resolve with time, but they may constitute an adjustment reaction if normal functioning is sufficiently disturbed.

Depression is both common and costly. It has a lifetime prevalence of 5 to 10 percent of women and 2 to 5 percent of men. It is an expensive disorder in both direct and indirect terms, as depression causes a higher degree of functional disability than many medical illnesses including diabetes, chronic lung disease, and arthritis. Additional costs to society result from the effect of untreated depression on the treatment of medical illnesses, where it contributes to longer hospital stays and morbidity. This has been particularly well demonstrated in the treatment of myocardial infarction (heart attack), where the presence of major depression has consistently been found to increase mortality.

Depressive illness is thought to result from a combination of biological and psychological factors. The biological component is strongly suggested by the high genetic concordance of depressive disorders. In the twenty-first century, there are various competing theories about the nature of this genetic/biological contribution, but the available data do not yet indicate the specific nature of the illness. The psychological component is similarly suggested by the correlation of onset of major depression with negative life events and with the increased risk of depression in individuals who experienced abuse in childhood. A variety of psychological theories exist and are linked to models of psychotherapeutic treatment. Interpersonal psychotherapists, for example, emphasize the role of grieving due to the loss of an important relationship or a transition in social roles (e.g., transition from working to retirement, marriage to divorce). Cognitive therapists emphasize a mind-set of construing life events in a way that leads to depression. Alternately, psychodynamic therapists search for the ways that unconscious coping processes and repetitive relational patterns result in negative effects. A commonly postulated mechanism would include the turning of anger in on the self. For example, a depressed woman may feel critical of herself rather than direct her anger toward an abusive spouse.

Treatment of depression parallels theories of etiology in that both biological and psychological treatments exist and have been efficacious. A number of different antidepressant medications have been developed, including monoamine oxidase (MAO) inhibitors, tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRI). These medicines have demonstrated efficacy in both the treatment of acute depressive episodes and in the prevention of relapses. A variety of psychological therapies are also employed in the treatment of depression. Interpersonal psychotherapy and cognitive behavioral psychotherapy are psychotherapeutic models for which depression-specific therapeutic techniques have been developed. These tend to be delivered in the form of brief semi-structured treatments, lasting less than a year in duration. One advantage of these approaches is that they have been well tested in research settings and have an established record of effectiveness in appropriately selected patients. There is also some clinical consensus that long-term psychodynamic (emphasizing unconscious mental processes) therapies are also helpful, especially when the mood disorder exists in the context of a long-standing personality disorder.

(SEE ALSO: Mental Health)

Bibliography

Eisendrath, S. J., and Lichtmacher, J. E. (1999). "Psychiatric Disorders." In Current Medical Diagnosis and Treatment 1999, eds. L. M. Tierney, S. J. Mcphee, and M. A. Papadakis. Stamford, CT: Appleton & Lange.

Gabbard, G. O. (1994). Psychodynamic Psychiatry in Clinical Practice: The DSM-IV Edition. Washington, DC: American Psychiatric Press.

Panzarino, P. J. (1998). "The Costs of Depression: Direct and Indirect: Treatment versus Nontreatment." Journal of Clinical Psychiatry 59(20):11–14.

— JAMES POWERS; STUART J. EISENDRATH

For more information on depression, visit Britannica.com.

1. Movement of the shoulder girdle or another body part downwards (i.e. in an inferior direction). Compare elevation.

2. A melancholy mood; a feeling of hopelessness, or an attitude of dejection. Depression can adversely affect the motivation to train and compete. In serious cases, depression is a symptom of mental illness. Exercise is often used in the treatment of mild depression and anxiety. Research has shown that aerobic exercise sustained for at least 30 min, five times a week can have anti-depressant effects, and the exercise produces physiological benefits that extend the range of activities that the patient can undertake with ease. Some of the psychological benefits are probably linked to an improved general feeling of well-being. In contrast, severe overtraining has been found to produce signs of depression in some athletes.

Depression is a mood disorder, understood from the psychoanalytical viewpoint as resulting from an intrapsychic conflict that stems from the ego's difficulties in integrating aggressive drives that are experienced as too dangerous for the preservation of libidinally cathected objects. These aggressive drives turn against the subject via the superego, which becomes too strict and demanding. Depressive manifestations are frequent in other clinical entities where the conflicts are essentially intrapsychic, such as the psychoneuroses.

Karl Abraham (1912/1989) was one of the first psychoanalytical authors to concern himself with depressed patients and to describe the extent of the ambivalence of their drives. Narcissism is another characteristic of the depressive personality, which that Freud emphasized in "Mourning and Melancholia" (1916-17g [1915]). Subsequently, Abraham (1924/1927) described the pregenital underpinning of this ambivalence, given the importance of oral fixations in these patients.

Freud compared the psychological mechanisms of melancholia with those of mourning, which constitutes a depressive state in the normal person. The essential difference is the narcissism of the melancholic, whose intolerance of experiences of loss lead him to the oral incorporation of the lost object into the ego, where it is attacked by the superego. Conversely, the person in mourning finds himself faced with the painful difficulty of detaching the libido cathected onto the lost object so as to recathect it onto objects in the external world. However, the major problem raised by Freud's descriptions of the dynamics of melancholia is that he does not specify the variations in the psychological mechanisms corresponding to the different degrees of depressive states.

Melanie Klein (1940) developed the comparison with mourning in her description of the depressive position. For her, the capacity to work through one's mourning will depend on the possibility of resolving the reactivation of the conflict proper to the depressive position that the conflict causes, i.e., the feeling of losing good internal objects. Klein, like Freud, is imprecise when it comes to the different problematics of depression. However, clinical analysis shows a whole series of levels of severity in this problematic between the working through of the mourning process (or during the integration of the depressive position) and the peak of this process, which Klein described as "a melancholia in statu nascendi" (Palacio Espasa). These depressive forms of conflict can be defined by reference to the predominant form of the fantasies expressing the experiences of the loss of the object of libidinal cathexis, and by the quality of the types of anxiety experienced by the ego.

When fantasies of the catastrophic and irreparable destruction of the object predominate, given that the subject has very little confidence in his libidinal capacities, feelings of guilt become intolerable and feelings of sadness are massively denied. The ego can only resort to archaic mechanisms of defense: splitting, denial, projective identification, idealization, etc.—the mechanisms proper to schizo-paranoid functioning or to the dynamics of extreme melancholia, with confusion between the ego and the object attacked (the "parapsychotic" depressive conflict proper to borderline or psychotic structures).

When fantasies of severe and barely reparable damage or death of the objects take the upper hand, the ego will be confronted with intense feelings of guilt and sadness. The significant repression of the aggressive drives towards the object (an aggressiveness that reinforces the severity of the superego) will make it possible for the negative affects to be partially denied. The ego will succeed in keeping the conflict interiorized but at the cost of diverse inhibitions in the functions of the ego. Thus, the symbolic possibilities of the individual are limited, but are not qualitatively affected. This very narrow form of repression is often insufficient, and the ego also has to resort to maniacal defenses or to defenses of a melancholic type, which then determine the clinical manifestations of mood disturbances.

When feelings of abandonment and rejection prevail—i.e., when the experiences of loss are above all fantasies such as the loss of the object's love—depressive conflict will take a "paraneurotic form." The feelings of sadness are often conscious, for guilt is less intense and can equally easily become conscious. The ego's greater confidence in its libidinal capacities gives these subjects a profusion of fantasies of reparation that will counteract the damage done to the object, damage that is fantasized as resulting from their own aggressiveness. These fantasies underlie many of the neurotic mechanisms of defense, especially those of an obsessional kind, for example retroactive cancelling, reaction formation, etc. Under their influence, repression authorizes a greater possibility of symbolic expression, which distinguishes neurotic repression from the massive repression of the depressive type. Such a libidinal predominance changes the nature of what is repressed, for the counter-cathexis does not operate on aggressiveness alone, but also on the libidinal fantasies of an incestuous nature. This contributes to the sexual differentiation of parental objects, bringing into operation the conflict occasioned by triangulation and the Oedipus complex.

Bibliography

Abraham, Karl. (1927). The process of introjection in melancholia: two stages of the oral phase of the libido. In Douglas Bryan and Alix Strachey (Trans.). Selected papers of Karl Abraham, M.D. (pp. 442-452). London: Hogarth. (Original work published 1924) ——. (1927). Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. In Douglas Bryan and Alix Strachey (Trans.), Selected papers of Karl Abraham, M.D. (pp. 137-156). London: Hogarth and the Institute of Psycho-analysis. (Original work published 1911)

Freud, Sigmund. (1916-17g [1915]). Mourning and melancholia. SE, 14: 237-258.

Klein, Melanie. (1940). Mourning and its relation to manic-depressive states. International Journal of Psycho-Analysis, 21, 125-153.

Palacio Espasa, Francisco. (1993). La Pratique psychothérapique avec l'enfant. Paris: Bayard.

—FRANCISCO PALACIO ESPASA

1. a hollow or depressed area.
2. a lowering or decrease of functional activity.
3. decreased interest in surroundings, decreased response to external stimuli. The least degree in a range of depressive mental states. See also somnolence, lassitude, narcolepsy, catalepsy, syncope, coma.

• d. fracture — important in the skull where they may penetrate brain tissue, introduce infection, or cause pressure on the brain because of hemorrhage or hematoma formation.

Quotes:

"It's a recession when your neighbor loses his job; it's a depression when you lose your own." - Harry S. Truman

"Depression is melancholy minus its charms -- the animation, the fits." - Susan Sontag

"In addition to my other numerous acquaintances, I have one more intimate confidant. My depression is the most faithful mistress I have known -- no wonder, then, that I return the love." - Soren Kierkegaard

"I am in that temper that if I were under water I would scarcely kick to come to the top." - John Keats

"The world leans on us. When we sag, the whole world seems to droop." - Eric Hoffer

"That terrible mood of depression of whether it's any good or not is what is known as The Artist's Reward." - Ernest Hemingway

See more famous quotes about Depression

This article is in need of attention from an expert on the subject. WikiProject Psychology or the Psychology Portal may be able to help recruit one. (February 2009)

For other uses, see Depression.

Not to be confused with Depressant or Depressants.

In the fields of psychology and psychiatry, the terms depression or depressed refer to sadness and other related emotions and behaviors. It can be thought of as either a disease or a syndrome.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) states that a depressed mood is often reported as feeling sad, helpless, and hopeless. In traditional colloquy, "depressed" is often synonymous with "sad," but both clinical depression and non-clinical depression can also refer to a conglomeration of more than one feeling.

Contents 1 Biology 2 Mechanism of adaptation 3 Psychiatric disorders 4 See also 5 References 6 External links

Biology

See also: Neurobiology

Biological influences of depression are varied, but may relate to malnutrition, heredity, hormones, seasons, stress, illness, drug or alcohol use, neurotransmitter malfunction, long-term exposure to dampness and mold^[1], back injury, and to aerosol exposure.^[2][3] There are also correlations between long term sleep difficulties and depression. Up to 90% of patients with depression are found to have sleep difficulties.^[4]

Mechanism of adaptation

While a depressed mood is usually referred to (and perceived) as negative, it can sometimes be subtly beneficial in helping a person adapt to circumstances. For example, physical illness, such as influenza, can lead to feelings of psychological malaise and depression that seem, at first, only to compound an already unpleasant situation.

However, the experience of depression, or feeling "down," often results in physical inertia, which leads to the compulsion to rest. The fleeting helplessness and immobility of the physically ill may also serve to elicit care from others."^[5]

From an evolutionary standpoint, some argue that depression could be at least partially related to atavistic fears that were originally based on real dangers. Paul Keedwell, in his book, How Sadness Survived: The Evolutionary Basis of Depression, suggests that, because "social support and interdependence were important features of the [human] ancestral environment," "the [peer] group could have offered extra help to the depressed person until the condition resolved."

Further, "...a depressed person may change the attitudes of other people around him, making them more sympathetic to his needs and therefore giving him a long term [social or reproductive] advantage."^[6]

Milder depression has been associated with what has been called depressive realism, or the "sadder-but-wiser" effect, a view of the world that is relatively undistorted by positive biases.^[7]

Psychiatric disorders

Main article: Types of psychological depression

Episodes of depressed mood are a core feature of the following psychological disorders, as specified by the DSM-IV:

• Major depressive disorder
• Dysthymia
• Bipolar disorder
• Cyclothymia
• Bulimia Nervosa
• Anorexia Nervosa
• Schizoaffective disorder
• Seasonal affective disorder (SAD)
• Adjustment disorder with depressed mood
• Postnatal depression
• Depressive Disorder Not Otherwise Specified

See also

• Treatment for depression
• Mood disorders
• Happiness

References

1. ^ Edmond D. Shenassa, Constantine Daskalakis, Allison Liebhaber, Matthias Braubach, and MaryJean Brown (2007). "Dampness and Mold in the Home and Depression: An Examination of Mold-Related Illness and Perceived Control of One’s Home as Possible Depression Pathways". American Journal of Public Health 97 (10): 1893. doi:10.2105/AJPH.2006.093773. PMID 17761567. http://www.ajph.org/cgi/content/abstract/97/10/1893. 
2. ^ Farrow, Alexandra (2003). "Symptoms of mothers and infants related to total volatile organic compounds in household products". Arch Environ Health 58 (10): 633–41. doi:10.3200/AEOH.58.10.633-641. PMID 15562635. 
3. ^ Air fresheners can make mothers and babies ill, University of Bristol press release issued 19 October 2004
4. ^ Roth T (2005). "Prevalence, associated risks, and treatment patterns of insomnia". J Clin Psychiatry 66 Suppl 9: 10–3; quiz 42–3. PMID 16336036. 
5. ^ Why We Get Sick: The New Science of Darwinian Medicine, Randolphe M. Nesse and George C. Williams | Vintage Books | 1994 | ISBN 0-8129-2224-7
6. ^ How Sadness Survived: The Evolutionary Basis of Depression, Marcello Spinella | Radcliffe Publishing | 2008 | ISBN 1846190134
7. ^ Taylor, SE (1991). Positive Illusions: Creative Self-deception and the Healthy Mind. New York, NY, USA: Basic Books. ISBN 0465060536. 

Notes

• "Study: Chronic Back Pain, Depression Related" by Regina Sass, 2007
• "Managing stress, depression and chronic back pain" William Deardorff, Ph.D & Grant Cooper, M.D.

External links

• Depression at the Open Directory Project
• Depression Research News at ScienceDaily
• National Alliance on Mental Illness – Depression support, advocacy, and education
• National Depressive and Manic Depressive Association - National Depressive and Manic Depressive Association
• Stanford Depression Research Clinic
• Substance Abuse and Mental Health Services (SAMHSA) – United States Department of Health and Human Services (HHS)
• Doing Well – Depression self-assessment and information from the UK National Health Service
• Depression information from mental health charity The Royal College of Psychiatrists

v • d • e Emotions (list) Acedia · Affection · Ambivalence · Anger · Angst · Annoyance · Anticipation · Anxiety · Apathy · Awe · Boredom · Bravery · Calmness · Compassion · Confusion · Contempt · Contentment · Curiosity · Depression · Desire · Disappointment · Disgust · Doubt · Ecstasy · Embarrassment · Empathy · Emptiness · Enthusiasm · Envy · Epiphany · Euphoria · Fanaticism · Fear · Frustration · Gratification · Gratitude · Grief · Guilt · Happiness · Hatred · Homesickness · Hope · Hostility · Humiliation · Hysteria · Inspiration · Interest · Jealousy · Kindness · Limerence · Loneliness · Love · Lust · Melancholia · Nostalgia · Panic · Patience · Pity · Pride · Rage · Regret · Remorse · Repentance · Resentment · Righteous indignation · Sadness · Saudade · Schadenfreude · Sehnsucht · Self-pity · Shame · Shyness · Suffering · Surprise · Suspicion · Sympathy · Weltschmerz · Wonder · Worry See also: Meta-emotion

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Dansk (Danish)
n. - depression, nedtrykthed, lavkonjunktur, krise, lavtryk, lavning, sænkning, nedtrykning

Nederlands (Dutch)
depressie (terneergeslagen stemming), depressie (economisch), depressie (lagedrukgebied/ lage luchtdruk), depressiviteit

Français (French)
n. - découragement, (Méd) dépression, état dépressif, (Géog) dépression, dépression (atmosphérique), (Écon) récession, abaissement (d'un levier, etc)

Deutsch (German)
n. - Depression, Senkung, Schwächung, Tiefdruckgebiet

Ελληνική (Greek)
n. - κατάθλιψη, μελαγχολία, γούβα, γούπατο, οικονομική ύφεση, οικονομική κρίση, (μετεωρ.) βαρομετρική ύφεση, (αστρον.) ταπείνωση, χαμήλωμα

Italiano (Italian)
depressione, esaurimento nervoso

Português (Portuguese)
n. - depressão (f)

Русский (Russian)
депрессия, зона низкого давления

Español (Spanish)
n. - bache, hoyo, recesión, depresión, frente de baja presión, inactividad, abatimiento

Svenska (Swedish)
n. - depression, lågkonjunktur

中文（简体）(Chinese (Simplified))
不景气, 沮丧, 消沉

中文（繁體）(Chinese (Traditional))
n. - 不景氣, 沮喪, 消沈

한국어 (Korean)
n. - (땅이) 움푹 꺼짐, 침울, 불황

日本語 (Japanese)
n. - 押し下げること, 下降, くぼみ, 低気圧, 不振, 不景気, 意気消沈, 憂鬱, 鬱病, 俯角, 凹み

العربيه (Arabic)
‏(الاسم) اكتئاب, كساد النشاط الاقتصادي والوظيفي, مكان مجوف في سطح شئ وبخاصه الأرض, حاله جويه ذات ضغط منخفض‏

עברית (Hebrew)
n. - ‮דכאון, שקע, גומה, שקע ברומטרי, תקופת שפל‬

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