• WHO ranks Depression as the 4th in the problems worldwide

• Most common mental disorder

• 1 or 2/ 10 mothers have depression after childbirth
• Affects more than 350 million people globally
• Women are twice more likely to be affected than men in depression; BPAD affects men and
women in same proportion
• Co-morbidity of /common cold of psychiatry (Seligman, 1975)
• Most significant risk factor for suicide (age standardized rate: 21.1 per 100,000 in 2012 in India)

Biological theories

• In 1960s and 1970s, mood disorders were thought as simple chemical imbalances of monoamine
neurotransmitters such as serotonin (5-HT), norepinephrine (NE) and dopamine (DA)
• These are specially found in larger proportion in the limbic system that regulates sleep, appetite,
emotions and memories

• PET scans indicate decreased activity in the frontal lobe of severely depressed individuals
• Endocrine System
• Elevated cortisol and the dexamethasone suppression test (DST)
• Dexamethasone depresses cortisol secretion
• Persons with mood disorders show less suppression

Behavioral models were the first learning approaches to be applied to depression.

Depression is more complex in its manifestations. It includes overt behavior (e.g., sad demeanor, slowed
activity, lack of responsiveness), cognition (e.g., low selfesteem, hopelessness, helplessness, negative view of
the world), and somatic symptoms (e.g., loss of weight, disturbed sleep, physical complaints) that extend
to almost all domains of functioning. While a precipitating event or theme can usually be identified, depression
is not stimulus-bound in the way anxiety is. Depression is more constant and pervasive.
REINFORCEMENT THEORY
One of the first to apply a behavioral analysis to the problem of depression was Charles Ferster (1973), who
viewed depression as a generalized reduction of rates of response to external stimuli. Behavior was then no
longer under the control of reinforcers that once were effective. Ferster’s basic analogy in learning terms was to
the process of extinction. Major losses in life could be seen as losses of important sources of reinforcement.
Generalization of the effects of the loss occurred because other behavior was chained to or organized by the
central source of reinforcement.

For example, for a man who becomes depressed after the break-up of a romance, the woman in the relationship
could be thought of as having been an important and central source of reinforcement. His relationship with her
may have organized much of the man’s behavior, chaining it to this source of reinforcement. If in his depression
he no longer goes to movies, a previously enjoyable activity (reinforcing), it is because he formerly went with
her and now that source of reinforcement is not available.

ii) Peter M. Lewinsohn developed similar ideas into a coherent theory and explored the ramifications of the
theory in a clinical research program (Lewinsohn, 1974; Lewinsohn, Biglan, & Zeiss, 1976). In Lewinsohn’s
terms, depression is a response to a loss or lack of response-contingent positive reinforcement. Insufficient
reinforcement in major domains of one’s life leads to dysphoria and a reduction in behavior, which are the
primary phenomena of depression. Other symptoms of depression such as low self-esteem and hopelessness
follow from the reduced level of functioning.

According to the theory, there are three ways in which insufficient reinforcement may arise. First, the
environment may be inadequate in providing sufficient reinforcement to maintain adequate functioning. For
example, the loss of a job or of a loved one would represent a significant loss of a source of reinforcement.
Inability to find a job, or a distressed marriage, might cause a continuing lack of reinforcement. Second, the
person may lack the requisite skills to obtain reinforcement in an environment where it is potentially available.
Poor interpersonal skills might prevent a person from developing satisfactory social relationships; poor
communication skills might maintain a distressed marital relationship. Third, the reinforcers might be available
to the person but he or she is unable to enjoy or receive satisfaction from them. The reason for this condition
would ordinarily be interfering anxiety. The socially anxious person does not functionally receive the
reinforcers, even if they are emitted by an amiable social environment.

II) LEARNED HELPLESSNESS THEORY

Induction by inescapable shock was seen as parallel to the traumatic loss that often precipitates depression. The
learned helplessness effect dissipated with time, as does normal depression.
When experimental analogs of the helplessness induction experiment were conducted with humans, findings
were similar.

Depressed subjects were slower to change their expectancies for success based on positive feedback, suggesting
a deficiency in perception of contingency.

• Three deficits:
• Motivational- paralysis of will: where individual shows no initiative
• Cognitive: where learning that one has no control interferes with one’s future ability to learn that
one does, in fact have control
• Emotional-learning that one has no control produces passivity and perhaps depression

The Attribution Revision

If depression is based on helplessness and the perception of noncontingency between the person’s behavior and
outcomes, then it is difficult to explain why people should perceive themselves responsible and blame
themselves for bad outcomes (Abramson & Sackheim, 1977).

In 1978 an attributional revision of the learned helplessness theory was published (Abramson, Seligman, &
Teasdale, 1978). The revision adapted the social psychological ideas about attribution of responsibility. When
people make inferences about the causes of events in their lives, these attributions can be categorized according
to a simple dimensional structure (Weiner et al., 1971).

Causes are either internal or external; that is, the event is caused either by some aspect of the person (skill,
personality, or effort) or by some aspect of the outside world (the task, another person, or chance). Secondly,
causal factors are either stable or unstable. That is, either they continue to function consistently over time
(skills; types of easy or difficult tasks) or they are relative to the particular time of the event (how much effort
was expended; luck)

Attributed causes can also be thought of as global or specific.

Depressed people habitually attribute negative outcomes to internal, stable, global causes and they credit
positive events to external, unstable, specific causes. In other words, following a failure the depressive person
accepts blame and assumes the cause is general and persisting. Following a success the same person takes no
credit and assumes the success has no implication for other behavior or for the future.

A person with this depressive style is likely to make a depressive attribution when a major aversive event
occurs. To make such an interpretation is to perceive oneself as helpless: I am unable to avoid failure and
unable to produce success. A depressive attributional style is a vulnerability or risk factor for making a
depressive attribution following an aversive event. The nature of that attribution will determine the
nature of the depression. An internal attribution determines whether the person’s self-esteem is affected,
a stable attribution determines the chronicity of the depression, and a global attribution determines the
generality of the feelings of depression. The intensity of the depression is determined not only by the
aversiveness of the event but by the person’s consequent attributions. The revision reconceptualizes wha t
was a behavioral animal model into a cognitive social psychological model.

• According to this theory, the type of ATTRIBUTION given to an event leads to depression
• Attributions, which are defined explanations for a person’s behaviour, are viewed across three critical
dimensions:
• Internal/external
• Global/specific
• Stable/unstable
• The theory proposes that attribution of loss of control serves as mediator between absence of control and
emergence of helplessness related deficits and depression
• A depressogenic attribution is one that is internal, stable, and global.
• This also serves as a diathesis for depression.

Response Contingent Positive Reinforcement Model (RCPR, Lewinsohn, 1974)

• Depression due to a low rate of RCPR

• When individuals receive a low rate of positive reinforcement for a particular behavioural response
(example, initiating a conversation), that behaviour gets extinguished.
• This subsequent loss of response based positive reinforcement deprives the individual of pleasure and
leads to feeling of dysphoria, low self-esteem, and hopelessness. These depressive symptoms are
 reinforced by a social environment of sympathy, interest and concern, thus rewarding and maintaining
depressed person’s low rate of responding.
• Poor social skills
• Negative life events, esp., those of loss diminish supply of potential reinforcers
Diathesis stress model
• Premise: Negative cognitions interact with life events to maintain Depression
• Diathesis: constitution vulnerability to develop a disorder
• Stress: severely threatening events—especially those that involve major loss of valued persons or
roles—represent a class of circumstances that appear to be especially effective for eliciting the
psychobiologic response (see Brown & Harris, 1986)
• Stress creates an important vulnerability for disorder
• On the other hand not all individuals, even those exposed to the most dire circumstances experience
psychopathology
• The basic premise is that stress activates a diathesis, transforming the potential of a predisposition into a
presence of a psychopathology.

ATTACHMENT MODEL
• According to attachment theory, children develop internal working models of self and others on the
basis of the responsiveness of their caregivers (Bartholomew, 1990; Bartholomew & Horowitz, 1991;
Bowlby, 1973, 1979; Pietromonaco & Feldman Barrett, 2000)
• In general, inconsistent parental responsiveness in childhood is believed to foster a negative working
model of self in adulthood.
• These adults, therefore, tend to see themselves as unworthy of care from others, doubt their value as
relationship partners, fear abandonment, and experience considerable attachment anxiety (Anxious
Attachment Style)
• In contrast, consistent non-responsiveness of parents in childhood is believed to foster the development
of adults who retain a negative working model of others, tend to remain on guard for interpersonal
disappointment, and distrust potential close relationship partners (Avoidant Attachment Style)

• Given that insecure attachment is comprised of two subtypes (anxious and avoidant), which result from
very different relational experiences, it is logical to expect that the pathways through which avoidant and
anxious individuals develop depression will differ.
• Avoidant individuals are mainly concerned with maintaining autonomy and control in their
relationships, which often results in emotional distancing
• Conversely, those who are high on anxious attachment tend to seek extreme closeness to their partners
and emotional reassurance, while holding an irrational fear of abandonment.
• These distinct differences in relational concerns should lead to depression develop through different
behavioural mechanisms for anxious and avoidant attachment

Interpersonal theory (Klerman et al., 1984)

• Based on attachment theory
• Further, based on maladaptive communication patterns as it impacts on interpersonal relationships
• Distress examined in connection to relationships
• Interpersonal crisis
• interpersonal disputes
• Role transitions
• Grief and loss
• Factors along with biopsychosocial/spiritual diathesis contribute to distress
• Uses a strengths approach

III)SELF-CONTROL THEORY
The relevance of models of self-control to depression was commented on early in the history of social learning
approaches to psychopathology (Bandura, 1971; Marston, 1964; Mathews, 1977). Models of self-control are
concerned with the ways in which people manage their behavior in order to obtain long-term goals (e.g., quit
smoking, or start exercising for long-term health). In depression, people are hopeless about long-term goals and
feel helpless to manage their own behavior. When a person becomes depressed, behavior organized by long-
term goals deteriorates first. The depressed person may continue to meet the immediate demands of daily
existence but behavior without immediate consequences is not performed. (eg rohit)

The self-control model of depression (Rehm, 1977) postulated that the behavior of depressed people could be
characterized by one or more of six deficits in self-control behavior. First, depressed persons selectively attend
to negative events in their lives, to the relative exclusion of positive events. This selfmonitoring deficit
describes the phenomenon discussed by Beck (1972) as selective attention in depression. Ferster (1973)
described this as the depressed person’s vigilance in anticipating aversive experiences. Second, depressed
people selectively attend to the immediate as opposed to the delayed consequences of their behavior. This might
be considered an overall effect of depressive self-control. Depressed persons have difficulty in looking beyond
the demands of the present when making behavioral choices.

Third, depressed people set stringent self-evaluative standards for themselves. Depressed people are often
perfectionistic. Standards for themselves are more stringent than those applied to others. Fourth, depressed
persons make depressive attributions about their behavior. Depressed persons make internal attributions for
failure and make external attributions for success.

Fifth, depressed people administer to themselves insufficient contingent reward to maintain important domains
of behavior, and sixth, they administer excessive self-punishment, which suppresses constructive behavior in
many areas. These deficits in the self-reinforcement phase of self-control are partly the consequence of deficits
in the earlier phases of self-control behavior. For example, to monitor negative events and set high standards
minimizes reward and maximizes punishment.

The nondepressed person is able to maintain behavior toward goals even when the external environment is not
reinforcing that behavior. The depressed person is dependent on external sources of reinforcement and becomes
depressed when they are insufficient, as suggested by Lewinsohn. When environmental contingencies change,
the individual is faced with organizing efforts to readjust and reorient toward distant goals.

IV) COGNITIVE THEORY

Beck’s Cognitive Theory

From modern cognitive psychology he adopted the theoretical construct of “schema.” Schemata are structural
units of stored information that also function to interpret new experience. They act as templates against which
new information is compared and incorporated.

Beck’s (1972) theory defined depression in cognitive terms. He saw the essential elements of the disorder as the
“cognitive triad”: (a) a negative view of self, (b) a negative view of the world, and (c) a negative view of the
future. The depressed person views the world through an organized set of depressive schemata that distort
experience about self, the world, and the future in a negative direction.

A number of typical forms of cognitive distortion were identified early in the development of the theory (Beck,
1963). Arbitrary inference involves the arbitrary assumption that some negative event was caused by oneself.
For example, a friend appears preoccupied and the depressed person thinks, “What did I do to make him
angry with me?” Selective abstraction occurs when the person focuses on the negative element in an otherwise
positive set of information. An employer, while congratulating the employee on a promotion, says, “Don’t
underestimate your future with this company.” The depressive employee thinks, “She thinks I have no
self-confidence.” Magnification and minimization involve overemphasizing negatives and underemphasizing
positives. Inexact labeling involves giving a distorted label to an event and then reacting to the label rather than
to the event. The conversation with the boss is labeled a “criticism session,” and the person anticipates being
fired.

It is a basic tenet of the cognitive approach that a schematic interpretation always mediates between an
experience and the emotional response to that experience. The negative, distorted cognitions that a person has in
a particular situation are termed “automatic thoughts.” They are automatic in the sense that the person is not
aware of the interpretive process and may not be aware even of the thoughts themselves but only of the
emotional consequences of the thoughts.

These specific thoughts can be distinguished from underlying assumptions, which are more basic interpretive
rules that form the automatic thoughts. In depression, the theme of the automatic thoughts is the perception of
loss.

Depressive schemata are activated when a major loss is perceived. An organized set of negative schemata,
formed earlier in life when major losses were experienced, replaces nondistorted schemata when the person
becomes depressed, and represents organized and elaborated views of self, the world, and the future. The
negative schemata may be replaced in use by more realistic schemata under usual life circumstances, but they
remain intact as “latent” schemata with the potential of reactivation under circumstances of loss.

The overgeneralization that occurs in depression is due to the replacement of one broad network of
schemata with another.

Beck hypothesized that cog Sx of D often precede mood Sx

Features of Beck’s THEORY:
1. Depressed people have underlying depressogenic schemas or dysfunctional beliefs- acquired early
in life through major life events such as death, loss. We order our lives through these schemes.
2. When dysfunctional beliefs are activated by current stressors in the environment, the negative
cognitive triad of an individual becomes activated
3. Fuelled by underlying cognitive errors/distortions that lead depressed person to misperceive
reality (Negative Automatic Thoughts)

Early Maladaptive Schemas, Young, 2003

• Stable trait-like cognitions; enduring patterns of one’s view of oneself and others, developed through
childhood and elaborated in one’s life experiences
 • Comprises of memories, bodily sensations, and emotions, which once activated, intense emotions are
experienced
• Three origins:
• Early childhood experiences
• Temperament
• Cultural influences

• EMSs are thought to be stable and perpetuated later in life even if the circumstances have changed.
• EMSs have become a part of the individual’s identity, and the individual behaves and interprets
situations in a way that confirms the schema
• Cognitive biases and self-defeating life-patterns maintain and strengthen EMSs, making the individual
vulnerable to depression, (Young, 1999)

The current schema list comprises 18 EMSs which are categorized in five domains:
1. Disconnection and rejection (abandonment/instability, mistrust/abuse, emotional deprivation,
defectiveness/shame, social isolation/alienation),
2. Impaired autonomy (dependence/incompetence, vulnerability for harm or illness,
enmeshment/undeveloped self, failure),
3. Impaired limit (entitlement/grandiosity, insufficient self-control/self-discipline),
4. Other-directedness (subjugation, self-sacrifice, and approval seeking/ recognition-seeking),
5. Over-vigilance and inhibition (negativity/pessimism, emotional inhibition, unrelenting standards,
punitiveness).

PSYCHODYNAMIC

Freud (1917, 1963) in “Mourning and Melancholia” conceptualized Depression in terms of 3 factors:
• Loss of an object or object’s love
• Ambivalent feelings toward that object
• Displacement of that feeling toward oneself

• Depression follows actual or symbolic loss, both of which activate feelings of failure and lack of
efficacy. But the reaction to loss in depression is both obscure and disproportionate.
• Person moves from external loss to inner world

Bibring (1953): tension between ideal and reality. Three highly invested narcissistic aspirations- to be
worthy and loved, to be strong and superior, and to be good and loving- are held as standards of conduct.
The ego’s awareness of inability to measure up to these leads to depression.

According to object relations theory, depression is caused by problems people have in developing
representations of healthy relationships. Depression is a consequence of an ongoing struggle that depressed
people endure in order to try and maintain emotional contact with desired objects. There are two basic ways that
this process can play out: the anaclitic pattern, and the introjective pattern.

Anaclitic depression involves a person who feels dependent upon relationships with others and who essentially
grieves over the threatened or actual loss of those relationships. Anaclitic depression is caused by the disruption
of a caregiving relationship with a primary object and is characterized by feelings of helplessness and weakness.
A person with anaclitic depression experiences intense fears of abandonment and desperately struggles to
maintain direct physical contact with the need-gratifying object.
Introjective depression occurs when a person feels that they have failed to meet their own standards or the
standards of important others and that therefore they are failures. Introjective depression arises from a harsh,
unrelenting, highly critical superego that creates feelings of worthlessness, guilt and a sense of having failure. A
person with introjective depression experiences intense fears of losing approval, recognition, and love from a
desired object.

Another modern derivative of psychodynamic theory, Coyne's interpersonal theory of depression has been
studied extensively, and forms the basis of a very effective treatment option known as Interpersonal Therapy or
IPT. According to interpersonal theory a depressed person's negative interpersonal behaviors cause other people
to reject them. In an escalating cycle, depressed people, who desperately want reassurance from others, start to
make an increasing number of requests for reassurance, and the other people (to whom those requests are made)
start to negatively evaluate, avoid, and reject the depressed people (or become depressed themselves)..
Depressed people's symptoms then start to worsen as a result of other people's rejection and avoidance of them.

Jacobson (1971): depressed people behave as if they were the worthless lost object. Eventually, this bad
internal object- or lost external love object- is transformed into a sadistic superego. A depressed person
then becomes a “victim of the superego, powerless and tortured by its cruel mother.” (Jacobson, 1971)

A Psychodynamic-Attachment Model of Depression (Holmes, 2013)

Three themes:
1. The centrality of loss
2. The role of childhood trauma
Primal emotions in depression: Self-attack as diverted aggression cannot be taken as a general theory of
depressive experience. A more nuanced picture, taking into account individual differences is needed.
Blatt (2008) classifies depression psychoanalytically into “anaclitic” (object leaning) and “introjective” (self-
absorbed) patterns.

Simpson and Belsky’s (2008) “psychic pain hypothesis.” Sensitivity to physical pain is an essential protective
mechanism for living organisms. Analogously, in the interpersonal environment, the capacity to experience
psychic pain on separation ensures that no effort is spared to maintain the attachments essential
for security and ultimate reproductive success. The capacity to become depressed in response to irretrievable
loss is the dark side of the life-enhancing virtues of intimate attachment. Those that feel no psychic pain on loss
may be protected from depression but risk deprivation through the superficiality of their attachments.

A second popular idea derives from “rank theory” (Neese, 2005). in social groups where rank and dominance
hierarchies prevail, loss lowers rank, rendering the sufferer vulnerable to reduced access to resources—food and
reproductive opportunities. The symptoms of depression such as loss of appetite and reduced libido can be
seen as adaptive in that by being temporarily hors de combat (out of action), the sufferer is no longer perceived
by potential rivals as a threat, and he can be allowed to recover in peace.

Although depression may be an adaptive response to loss of status and rank, this view also suggests that
societies where rank anxiety are prevalent will also have high depression rates.

MELANIE KLIEN’S THEORY OF DEPRESSIVE POSITION

Depression occurs when:

(a) People feel abandoned
(b) There is an experience of rage and outrage
 (c) They protect the object from their rage by identification, taking the battle into the self, but
(d) This anger toward the object arouses guilt and depression then becomes a punishment befitting the
crime.
(e) Finally if, in the “depressive position” one can “reinstate” the whole object in one’s inner world, in both
its loving and abandoning aspects, then one is inured against further loss (Klein, 1940).

EXISENTIAL THEORY

• Existential Vacuum: when individuals do not consistently affirm their freedom and responsibility, do not
acknowledge their motivation to find meaning in life, letting this instead take a back seat to the pursuit
of pleasure or power—or when they are simply unable to find a purpose that they feel uniquely meant to
pursue, then they presumably experience a vacuum (Frankl)
• And when someone with such a vacuum is confronted with significant life stress, an existential neurosis
can be triggered

Culture and depression (Kleinman, 2004

• In many parts of society, the experience of depression is physical rather than psychological.
• Example, many depressed people do not report feeling sad, but rather express boredom, discomfort,
feelings of inner pressure, and symptoms of pain, dizziness, and fatigue.