INTRODUCTION
The term ”depression” covers a wide range of thoughts, behaviors, and feelings. It is also one of the most commonly used terms to describe a wide range of negative moods. In fact there are many types of depression, each of which vary in the number of symptoms, their severity, and persistence. The prevalence of depression is surprisingly high. Between 5 and 12 percent of men and 10 to 20 percent of women in the United States will suffer from a major depressive episode at some time in their lives. Approximately half of these individuals will become depressed more than once, and up to 10 percent will experience manic phases where they are elated and excited, in addition to depressive ones; an illness known as ”manic-depressive” or bipolar disorder. Depression can involve the body, mood, thoughts, and many aspects of life. It affects the way people eat and sleep, the way they feel about themselves, and the way they think about things. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.
TYPES OF DEPRESSION
Depression can be experienced for either a short period of time or can extend for years. It can range from causing only minor discomfort, to completely mentally and physically crippling the individual. The former case of short-term, mild depression is what is most commonly referred to as ”the blues” or when people report ”feeling low.” It is technically referred to as dysphoric mood. Feelings of depression tend to occur in almost all individuals at some point in their lives, and dsyphoric mood has been associated with many key life events varying from minor to major life transitions (e.g., graduation, pregnancy, the death of a loved one). The feelings of separation and loss associated with leaving a town one has grown up in, moving to a new city for a job or school, or even leaving a work environment that one has grown accustomed to, can cause bouts of depression signaled by a loss of motivation and energy, and sadness. Other common features of dysphoric mood, include sighing, an empty feeling in the stomach, and muscular weakness, are also associated with changes such as the breakup of a dating relationship, divorce, or separation. In the case of bereavement, most survivors experience a dysphoric mood that is usually called grief (although some studies have shown that these feelings may be distinct from depression).
Many of these feelings are seen as representing the body’s short-term response to stress. Other kinds of stressful events like losing a job; being rejected by a lover; being unable to pay the rent or having high debts; or losing everything in a fire, earthquake, or flood; may also bring on feelings of depression. Most of these feelings based on temporary situations are perfectly normal and tend to fade away.
A more severe type of depression than dysphoric mood, dysthymia (from the Greek word for defective or diseased mood), involves long-term, chronic symptoms that do not disable, but keep those individuals from functioning at their best or from feeling good. People with dysthymia tend to be depressed most of the day, more days than not, based on their own description or the description of others. Dysthymics have a least two of the following symptoms: eating problems, sleeping problems, tiredness and concentration problems, low opinions of themselves, and feelings of hopelessness. Unlike major depression, dysthymics can be of any age. Often people with dysthymia also experience major depressive episodes.
If ”the blues” persist, it is more indicative of major depression, also referred to as clinical depression or a depressive disorder. Major depression is manifested by a combination of symptoms that interfere with the ability to work, sleep, eat, and enjoy once-pleasurable activities. These disabling episodes of depression can occur once, twice, or several times in a lifetime. Clinical practitioners (both clinical psychologists and psychiatrists) make use of a multiple-component classification system designed to summarize the diverse information relevant to an individual case rather than to just provide a single label. Using a specified set of criteria in the Diagnostic and Statistical Manual of Mental Disorders (referred to as DSM-IV, American Psychiatric Association 1994), a diagnosis of depressive disorder includes symptoms such as dissatisfaction and anxiety; changes in appetite, sleep, and psychological and motor functions; loss of interest and energy; feelings of guilt; thoughts of death; and diminished concentration. It is important to keep in mind that many of these symptoms are also reported by individuals who are not diagnosed with clinical depression. Only having many of these symptoms at any one time qualifies as depression. An individual is said to be experiencing a ”major depressive episode” if he or she experiences a depressed mood or a loss of interest or pleasure in almost all activities and exhibits at least four other symptoms from the following list: marked weight loss or gain when not dieting, constant sleeping problems, agitated or greatly slowed-down behavior, fatigue, inability to think clearly, feelings of worthlessness, and frequent thoughts about death or suicide. Anyone experiencing these symptoms for a prolonged period of time should see a doctor or psychiatrist immediately.
Another type of depression is bipolar disorder, formerly called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder involves interspersed periods of depression and elation or mania. Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, individuals have any or all of the symptoms of a depressive disorder. When in the manic cycle, individuals tend to show inappropriate elation, social behavior, and irritability; have disconnected and racing thoughts; experience severe insomnia and increased sexual appetite; talk uncontrollably; have grandiose notions; and demonstrate a marked increase in energy. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, unwise business or financial decisions may be made when an individual is in a manic phase. Bipolar disorder is often a chronic condition. For more details on types of depression, including symptoms, see either a good textbook on abnormal psychology (e.g., Sarason and Sarason 1999), DSM-IV (American Psychiatric Association 1994) or use the search term ”depression” on the web site for the National Institute of Health (http://search.info.nih.gov/).
THEORIES OF DEPRESSION
Most theorists agree that depression can be best studied using what health psychologists refer to as a biopsychosocial approach. This holds that depression has a biological component (including genetic links and biochemical imbalances), a psychological component (including how people think, feel, and behave), and a social component (including family and societal pressures and cultural factors). Individual theories have tended to emphasize one or the other of these components. The main theories of depression are biological and cognitive in nature, although there are also psychodynamic and behavioral explanations which are discussed below.
Psychodynamic Theories of Depression. The psychological study of depression was essentially begun by Sigmund Freud and Karl Abraham, a German physician. Both described depression as a complex reaction to the loss of a loved person or thing. This loss could be real or imagined, through death, separation, or rejection. For Abraham (1911/ 1968), individuals who are vulnerable to depression experience a marked ambivalence toward people, with positive and negative feelings alternating and blocking the expression of the other. These feelings were seen to be the result of early and repeated disappointments. Depression, or melancholy, as Freud called it, was grief out of control (Freud 1917/1957). Unlike those in mourning, however, depressed persons appeared to be more self-denigrating and lacking self-esteem. Freud theorized that the anger and disappointment that had previously been directed toward the lost person or thing was internalized, leading to a loss of self-esteem and a tendency to engage in self-criticism. Theorists who used a similar approach and modified Freud’s theories for depression were Sandot Rado and Melanie Klein, and most recently John Bowlby (1988).
Behavioral Theories of Depression. In contrast to a focus on early-childhood experiences and internal psychological processes, behavioral theories attempt to explain depression in terms of responses to stimuli and the overgeneralization of these responses. For example, loss of interest to a wide range of activities (food, sex, etc.) in response to a specific situation (e.g., loss of ajob). The basic idea is that if a behavior is followed or accompanied by something good (a reward), the behavior will increase and persist. If the reward is taken away, lessened, or worse still, if the behavior is punished, the behavior will lessen or disappear. B. F. Skinner, a key figure in the behaviorist movement, postulated that depression was the result of a weakening of behavior due to the interruption of an established sequence of behavior that had been positively reinforced by the social environment. For example, the loss of a job would stop a lot of the activities that having a salary provides (e.g., dining out often, entertainment). Most behavioral theories extended this idea, focusing on specific others as the sources of reinforcement (e.g., spouses, friends).
Cognitive Theories of Depression. Although it is probably indisputable that the final common pathways to clinical depression and even dysphoric mood involve biological changes in the brain, the most influential theories of depression today focus on the thoughts of the depressed individual. This cognitive perspective also recognizes that behavior and biochemistry are important components of depression, but it is more concerned with the quality, nature, and patterns of thought processes. Cognitive therapists believe that when depressive cognitions are changed, behavior and underlying biological responses change as well. Cognitive theories of depression differ from behavioral theories in two major ways (see Gotlieb and Hammen 1992 for a more detailed description). First, whereas behavioral theories focus on observable behaviors, cognitive theories emphasize the importance of intangible factors such as attitudes, self-statements, images, memories, and beliefs. Second, cognitive approaches to depression consider maladaptive, irrational, and in some cases, distorted thoughts to be the cause of the disorder and of its exacerbation and maintenance. Depressive behaviors, negative moods, lack of motivation, and physical symptoms that are seen to accompany depression are all seen as stemming from faulty thought patterns. There are three main cognitive theories of depression: Beck’s cognitive-distortion model, Seligman’s learned helplessness model, and the hopelessness theory of depression.
Beck’s cognitive-distortion model. The most influential of these theories is Aaron Beck’s cognitive-distortion model of depression (1967). Beck believes that depression is composed of three factors: negative thoughts about oneself, the situation, and the future. A depressed person misinterprets facts in a negative way, focuses on negative aspects of a situation, and has no hope for the future. Thus any problem or misfortune experienced, like the loss of a job, is completely assumed to be one’s own fault. The depressed individual blames these events on his or her own personal defects. Awareness of these presumed defects becomes so intense that it overwhelms any positive aspects of the self and even ambiguous information is interpreted as evidence of the defect in lieu of positive explanations. A depressed person might focus on a minor negative exchange within an entire conversation and interpret this as a sign of complete rejection. These types of thought patterns, also referred to as ”automatic thoughts” when responses based on insufficient information are made, are persistent and act as negative filters for all of life’s experiences.
Together with the idea that depressed individuals mentally distort reality and engage in faulty processing of information, the most important part of Beck’s cognitive model of depression is the notion of a ”negative self-schema.” A schema is a stored body of knowledge that affects how information is collected, processed, and used, and serves the function of efficiency and speed. In the context of depression, schemas are mental processes that represent a stable characteristic of the person, influencing him or her to evaluate and select information from the environment in a negative and pessimistic direction. Similar to psychoanalytical theories, negative self-schemas are theorized to develop from negative experiences in childhood. These schemas remain with the individual throughout life, functioning as a vulnerability factor for depression. Cognitive treatments of depression necessarily work to change these negative schemas and associated negative-automatic thought patterns.
Seligman’s learned helplessness model. Based on work on animals (later replicated in humans), Martin Seligman’s (1975) theory of learned helplessness and his model of depression holds that when individuals are exposed to uncontrollable stress they fail to respond to stimulation and show marked decrements in the ability to learn new behaviors. Because this theory did not sufficiently account for the self-esteem problems faced by depressed individuals, it was reformulated by Abramson who hypothesized that together with uncontrollable stress, people must also expect that future outcomes are uncontrollable. When they believe that these negative uncontrollable outcomes are their own doing (internal versus external), will be stable across time and will apply to everything they do (global), they feel helpless and depressed.
Hopelessness theory of depression. The most recent reformulation of the learned helplessness theory, referred to as the ”hopelessness theory” of depression (Abramson, Seligman, and Alloy 1989) holds that depression is a result of expectations that highly undesired outcomes will occur and that one is powerless to change these outcomes. The hopelessness theory of depression is receiving a large amount of attention as it has been found to be particularly useful in predicting the likelihood of suicide among depressed people.
Biological Theories of Depression. The most compelling of the recent theories of depression rely heavily on the biological bases of behavior. Biological theories assume the cause of depression lies in some physiological problem, either in the genes themselves or in the way neurotransmitters (the chemicals that carry signals between nerve cells in our brains and around our bodies) are produced, released, transported, or recognized (see Honig and van Praag 1997 for a detailed review of biological theories of depression). Most of the work focuses on neurotransmitters, especially a category of chemicals in our bodies called the monoamines, the main examples of which are norepinephrine (also called noradrenalin), dopamine, and serotonin. These chemicals first attracted attention in the 1950s when physicians discovered that severe depression arose in a subset of people who were treated for hypertension with a drug (reserpine) that depleted monoamines. Simultaneously, researchers found that a drug that increased the monoamines, this time given to medicate tuberculosis, elevated mood in users who were depressed. Together these results suggested that low levels of monoamines in the brain cause depression. The most important monoamine seems to be norepinephrine although it is now acknowledged that changes in levels of this neurochemical do not influence moods in everyone. Nevertheless, this biochemical theory has received much experimental support.
Apart from the neurochemicals, there are also other physiological differences between depressed and nondepressed individuals. Hormones are chemical substances that circulate in the blood and enable communication between different systems of the body. Some hormones control the release of other hormones which then stimulate growth and help prepare the body to deal with, and respond to, stress (e.g., adrenocorticotropic hormone or ACTH). Depressed patients have repeatedly been demonstrated to show abnormal functioning of these hormones (see Nemerof 1998 for a detailed review). Another difference is seen in one of the major systems of the body that affects how we respond to stress; the hypothalamic-pitui-tary-adrenal (HPA) axis. From the late 1960s and early 1970s, researchers have found increased activity in the HPA axis in unmedicated depressed patients as evidenced by increased levels of stress markers in bodily fluids. Now a large volume of studies confirm that substantial numbers of depressed patients display overactivity of the HPA axis. According to Charles Nemeroff (1998) and his colleagues, and based on studies on animals, all these biological factors including genetic inheritance of depression, neurotransmitter and hormonal levels, and HPA axis and related activity, could relate to early childhood abuse or neglect, although this theory has yet to be fully substantiated. The antecedents and consequences notwithstanding, it is well accepted that one of the major causes of depression is based in our biology.
RISK FACTORS
Depression can have many different causes as indicated by the different theories that have been formulated to explain it. Accordingly, there are different factors that indicate a risk for depression. Some of the main risk factors for long-term depression include heredity, age, gender, and lack of social support.
Studies of twins and of families clearly suggest a strong genetic component to clinical depression, which increases with genetic closeness. There is a much greater risk of developing a major depression if one’s identical twin has had it than if one’s parent, brother, or sister developed it. Chances are even less if no close relatives have ever had it. Furthermore, the younger people are when they experience depression, the higher the chances that one of their relatives will also get severely depressed. Relatives of people who were over forty when they first had a major depression have little more than the normal risk for depression.
One of the most clear risk factors is gender. Women are at least twice as likely to experience all types of depressed states than are men and this seems to occur from an early age. There are no gender differences in depression rates in prepubescent children, but after the age of fifteen, girls and women are about twice as likely to be depressed as boys and men. Many models have been advanced for how gender differences in depression might develop in early adolescence. For example, one model suggests that the causes of depression can be assumed to be the same for girls and boys, but these causes become more prevalent in girls than in boys in early adolescence. According to another model, there are different causes of depression in girls and boys, and the causes of girls’ depression become more prevalent than the causes of boys’ depression in early adolescence. The model that has received the most support suggests that girls are more likely than boys to carry risk factors for depression even before early adolescence, but these risk factors lead to depression only in the face of challenges that increase in early adolescence (Nolen-Hoeksema and Girgus 1994). For a review of the epidemiology of gender differences in depression including prominent theories for why women are more vulnerable to depression, cross-cultural studies of gender differences in depression, biological explanations for the gender difference in depression (including postpartum depression, premenstrual depression, pubescent depression), personality theories (relationship with others, assertiveness), and social factors for the gender difference (increases in sexual abuse in adolescent females) see Susan Nolen-Hoeksema (1995).
Age by itself is a major risk factor for depression, although as described this varies for each gender. For women, the risk for a first episode of depression is highest between the ages of twenty and twenty-nine. For men, the risk for a first episode is highest for those aged forty to forty-nine. A related risk concerns when a person was born. People born in recent decades have been found to have an increased risk for depression as compared to those born in earlier cohorts.
Another significant risk factor for depression is the availability and perception of social support. People who lack close supportive relationships are at added risk for depression. Additionally, the presence of supportive others may prevent depression in the face of severe life stressors. Support is especially important in the context of short-term depression that can result from events like conflictual work or personal interactions, unemployment, the loss of a job, a relationship break-up, or the loss of a loved one.
MEASUREMENT OF DEPRESSION
Most of the commonly used techniques to assess for depression come from clinical psychology and are heavily influenced by the cognitive theories of depression. For example, the work of Beck and other cognitive theorists has led to the development of many ways to measure the thoughts that depressed individuals may have. Most of these measures are completed by the individuals themselves, while some are administered in an interview format where the therapist asks a series of questions. Some interviews are delivered by trained clinical administrators (e.g., the Structured Clinical Interview for DSM-IV), while others are highly structured, can be computer scored to achieve diagnoses based on the DSM-IV, and can be administered by lay interviewers with minimal training (e.g., the Diagnostic Interview Schedule). Separate measures have also been designed for adults and children to compensate for differences in level of comprehension and sophistication, although measures of symptoms and diagnoses in children and adolescents are less-extensively studied. The methods used work well for children provided that information from both parent and child sources are included in the final decisions.
There are different types of self-report measures for depression. It can be assessed by having the patient fill out a questionnaire. Because our thought processes may operate at varying levels of consciousness, we may not always be able to access what they are to report on them. For this reason different cognitive measures of depression were designed to operate at various levels of consciousness. For example, the most direct measures ask about the frequency with which negative automatic thoughts have ”popped” into a person’s head in the past week (e.g., ”no one understands me”). Another type of measure attempts to get at the cognitive and social cognitive mechanisms by which people formulate their beliefs and expectations. Because many negative thoughts take the form of comparing the self with others, these types of scales try to understand the negative comparisons. An example of this type of measure is one where individuals are asked about the circumstances (interactions with people, idle thoughts, etc.), the dimensions (social skills, intelligence), the gender, and the type of relationship with the comparison target, and the individual’s mood before and after the interaction. To get at the least-accessible level of thoughts, those that are believed to store, organize, and direct the processing of personally relevant information, researchers have used measures like the Stroop color-word task. Individuals are asked to name the color of the ink in which a word is printed but to ignore the meaning of the word itself. Slower response rates are thought to indicate greater effort to suppress words that are highly descriptive of the self. For example, depressed individuals take longer to name the color in which words like ”sad” and ”useless” are printed compared to the color for positive words.
In health, clinical, and counseling research and evaluation settings, the two most common measures of depression are the Beck Depression Inventory (BDI) and the Center for Epidemiological Studies Depression Scale (CESD). The BDI was designed to measure ”symptom-attitude categories” associated with depression (Beck 1967). These include, among others, mood, pessimism, and sense of failure as well as somatic preoccupation. Many of the items reflect Beck’s belief in the relevance of negative cognitions or self-evaluations in depression. Each item includes a group of statements that reflect increasing levels of one of these symptom-attitude categories. The test taker is asked to choose the statement within each item that reflects the way he or she has been feeling in the past week. The items are scored on a scale from 0-3, and reflect increasing levels of negativity. A sample item includes 0 = ”I do not feel like a failure,” to 3 = ”I feel I am a complete failure as a person.” The CESD is a twenty-item scale, is a widely used measure of depressive symptomatology, and has been shown to be valid and reliable in many samples. Participants are asked to best describe how often they felt or behaved during the previous week, in a variety of ways reflective of symptoms of depression, using a scale ranging from 0 (Rarely or none of the time[less than 1 day]) to 3 (Most or all of the time [5-7 days]). For example, participants are asked how often their sleep was restless or they felt that everything they did was an effort. Other self-report measures include the Minnesota Multiphasic Personality Inventory Depression Scale (MMPI-D), the Zung Self-Rating Depression Scale (SDS), and the Depression Adjective Check List (DACL). Complete descriptions of these scales can be found in Constance Hammen (1997).
TREATMENT
As can be expected, the type of treatment depends on the type of depression and to some extent the favored theory of the health-care provider (physician, psychologist, or therapist) one goes to for treatment.
Biologically based treatments. The most common treatment for depression that is thought to have a physiological basis is antidepressant medication. Based on biological theories suggesting that depression results from low levels of the monoamines serotonin, norepinephrine, and dopamine, antidepressant medications act to increase the levels of these chemicals in the bloodstream. These drugs work by either preventing the monoamines from being broken down and destroyed (referred to as monoamine oxidase (MOA) inhibitors and tricyclics) or by preventing them from being removed from where they work (referred to as selective serotonin inhibitors [SSRIs]). Elavil, Norpramin, and Tofranil are the trade names of some MAO inhibitors. Prozac, Paxil, Zoloft, and Luvox are examples of SSRIs.
Although these medications have been proven to be effective in reducing depression, they also have a variety of side effects and need to be taken only under medical supervision. For example, tricyclics also cause dry mouth, constipation, dizziness, irregular heartbeat, blurred vision, ringing in the ears, retention of urine, and excessive sweating. Some of the SSRIs were developed with an eye toward reducing side effects and are correspondingly more often prescribed. Unfortunately, they are most commonly associated with prescription drug overdoses resulting in many thousands of deaths a year.
Several medicinal herbs have antidepressant effects. The most powerful is St. John’s wort, a natural MAO inhibitor. In addition, ginkgo and caffeine may also help. Although much more research remains to be done, studies to date support the effectiveness of such alternative medicine. For example, a group of researchers in Texas, in collaboration with German scientists, surveyed studies including a total of 1,757 outpatients with mainly mild or moderately severe depressive disorders, and found that extracts of St. John’s wort were more effective than placebos (i.e., inactive pills) and as effective as standard antidepressant medication in the treatment of depression. They also had fewer side effects than standard antide-pressant drugs (Linde et al. 1996).
In extreme cases of depression when drugs have been tried and found to not have an effect, and when the patient does not have the time to wait for drugs to take an effect (sometimes up to two or three weeks), electroconvulsive therapy (ECT) is recommended. ECT involves passing a current of between 70 and 130 volts through the patient’s head after the administration of an anesthetic and muscle relaxant (to prevent injury from the convulsion caused by the charge). ECT is effective in treating severe depression although the exact mechanisms by which it works have not been determined.
Cognitive treatments. Cognitive therapists focus on the thoughts of the depressed person and attempt to break the cycle of negative automatic thoughts and negative self-views. Therapy sessions are well structured and begin with a discussion of an agenda for the session, where a list of items is drawn up and then discussed one by one. The therapist then tries to identify, understand, and clarify the misinterpretations and unrealistic expectations held by the client. Therapists use several techniques to identify these thoughts including asking direct questions, asking the client to use imagery to evoke the thoughts, or role-playing. Identifying these thoughts is a critical part of cognitive therapy and clients are also asked to keep daily diaries to list automatic thoughts when they occur as they are often unnoticed by depressed individuals. The client is then asked to provide a written summary of the major conclusions from the session to solidify what has been achieved and finally, the therapist prescribes a ”homework assignment” designed to help the client practice skills and behaviors worked on during the session. Behavioral therapy is closely related to cognitive therapy and involves training the client to have better social skills and behaviors that enable them to develop better relationships with others.
Which are more effective treatments: cognitive or biological? A large National Institute of Mental Health study suggests that there is little difference in the effectiveness of the two therapies although the two treatments seem to produce different effects over time. Patients who received cognitive therapy were less likely to have a return of depression over time as compared to patients with biological therapy, although the small sample size used in this study precludes a definite answer to this question. Both therapies have been found to be effective, and it is likely that one is better with some forms of depression than the other, depending on how long the person has been depressed and the exact nature of his or her symptoms. In general both treatments, whether cognitive or biological, are recommended to be continued for a short time after the depressed episode has ended in order to prevent relapse.
CONCOMITANTS
A wide body of research has documented the links between depression and a wide variety of other factors. It is both a component of many other psychological disorders as well as something that follows many other disorders. In fact, some studies have shown that out of all the people at a given time with depression, only 44 percent of them display what can be called ”pure” depression, whereas the others have depression and at least one other disorder or problem. The most common of these associated problems are anxiety, substance abuse, alcoholism, and eating disorders (see Hammen 1997 for more details). Given the symptoms of depression, individuals with the disorder also experience associated social problems including strained relationships with spouses, family, and friends, and in the workplace. Most alarming perhaps is that the children of depressed parents (especially mothers) are especially at risk for developing problems of their own.
Depression has also been linked to positive factors although not always with good results. For example, there is some evidence that depression is linked to creativity. Artists tend to suffer more than their share of depression according to psychiatrists at Harvard medical school, who charted the psychological histories of fifteen mid-twentieth-century artists. They found that at least half of them, including artists like Jackson Pollock and Mark Rothko, suffered from varying degrees of depression (Schildkraut and Aurora 1996). Many of these artists eventually committed suicide, which is perhaps one of the most significant and dangerous results of depression. At least 15 percent of people with depression complete the act of suicide, but an even higher proportion will attempt it. Consequently, individuals with severe cases of depression may experience many suicide-related thoughts and sometimes need constant surveillance.
Depression is often seen in patients with chronic or terminal illnesses and in patients who are close to dying. For example, depression is a common experience of AIDS patients, and is related to a range of factors such as physical symptomatology, number of days spent in bed, and in the perceived sufficiency of social support. Depression has also been linked to factors that influence mortality and morbidity. Higher depressed mood has been significantly associated with immune parameters pertinent to HIV activity and progression: lower levels of CD4 T cells, immune activation, and a lower proliferative response to PHA (a natural biological reaction that is essential to good health). Depression is also a critical variable with respect to compliance with treatment, especially in HIV-positive women of low-socioeconomic status.
Depression is strongly related to the number and duration of stressors experienced, or chronic burden. Chronic burden, defined by Leonard Pearlin and Carmi Schooler (1978) as ongoing difficulties in major social roles, including difficulties in employment, marriage, finances, parenting, ethnic relations, and being single/separated/divorced contributes to depression and increases vulnerability to health problems by reducing the ability of the body to respond to a physiological challenge, such as mounting an immune response to a virus. Related to chronic burden, many aspects of depression are concomitants of low-socioeconomic status, traditionally measured by education, income, and occupation. Research showing clear social-class differences in depression also suggest the contribution of the stress of poverty, exposure to crime, and other chronic stressors that vary with social class. Jay Turner, Blair Whea-ton, and David Lloyd (1995) found that individuals of low-socioeconomic status were exposed to more chronic strain in the form of life difficulties in seven domains (e.g., parenting, relationships, and financial matters) than individuals of high-socioeconomic status, which could account for higher levels of depression.
The influence of culture is one factor that has not been sufficiently studied in the context of depression. To date, most clinical-disorder classification systems do not sufficiently acknowledge the role played by cultural factors in mental disorders. The experience of depression has very different meanings and forms of expression in different societies. Most cases of depression worldwide are experienced and expressed in bodily terms of aching backs, headaches, fatigue, and a wide assortment of symptoms that lead patients to regard this condition as a physical problem (Sarason and Sarason 1999). Only in contemporary Western societies is depression seen principally as an internal psychological experience. For example, many cultures tend to view their mental health problems in terms of physical bodily problems. That is, they tend to manifest their worries, guilt feelings, and strong negative emotions (such as depression) as physical complaints. This could be because bodily complaints do not carry the stigma or negative social consequences that psychological problems do, and are correspondingly easier to talk about.
Although not an essential part of aging, many people over age sixty-five develop clinical depression. Surveys suggest that only about 5 percent of healthy elderly people living independently suffer depression at any given moment, but more than 15 percent experience depression at some point during their elderly years, and the condition tends to be more chronic than in younger people. In addition, some 25 percent of elderly individuals experience periods of persistent sadness that last two weeks or longer, and more than 20 percent report persistent thoughts of death and dying. The likelihood of depression varies with the situation the person is in, and is more likely when the elderly person is away from his or her family in a novel setting. For example, some 20 percent of nursing home residents are depressed. Depression is also antagonized by serious medical conditions that elderly men and women may have. Correspondingly, depression is commonly associated with illnesses like cancer, heart attack, and stroke. Depression often goes undiagnosed and untreated in the elderly and is something that caregivers (spouse, children, family, and friends) should be especially watchful for given the relationship between depression and suicide.
CONCLUSIONS
Many people still carry the misperception that depression is either a character flaw, a problem that happens because of personal weaknesses, or is completely ”in the head.” As described above, there are psychological, physiological, and societal components to depression. Most importantly, it is something that can and should be treated. There are too few people who see a doctor when they recognize symptoms of depression or think of getting medical treatment for it. Depression is so prevalent that it is often seen as a natural component of life events like pregnancy and old age, and depressed mothers and elderly men and women often do not get the attention they need. Today, much more is known about the causes and treatment of this mental-health problem, with the best form of treatment being a combination of medication and psychotherapy. Depression need not be ”the end.”
