Po. in Depression Fayez El-Gabalawi Depressive Disorders: Definition and Prevalence Depressive disorders consist of a group of psy- chiatric disorders in which pathological moods and related vegetative and psychomotor distur bances dominate the clinical picture. Previously, they were part of mood disorders, affective disor- ders, manic-depressive disorder, dysthymic and cyclothymic disorders, and they are better con- ceived as syndromes rather than discrete disease categories [1]. Before discussing the concept of major depression from the historical and devel- ‘opmental point of view, let us examine how per- vasive it is as a major public concern in the United States and in the world in general. According to the National Institute of Mental Health (NIMR), major depression is one of the most common mental disorders in the United States. For some individuals, major depression can result in severe impairments that interfere with or limit one’s ability to carry out major life activities. The past year prevalence data presented here for major depressive episode are from the 2016 National Survey on Drug, Use and Health (NSDUH). The NSDUH study defi- nition of major depressive episode is based mainly on the fourth edition of the Diagnostic and Statistical ‘Manual of Mental Disorders (DSM-IV). F.El-Gabalawi (©) ‘Thomas Jefferson University Hospital, Philadelphia, PA, USA e-mail: Fayez.el-gabalawi @jefferson.edu © Springer Nature Switzerland AG 2020 “ren ‘ive Interventions Box 9.1: Depression Prevalence 1, Past year prevalence of major depres- sive episode among U.S. adults in 2016 was 6.7% (female 8.5%, male 4.8%). 2. Age groups differed in their prevalence (age 18-49 was 7.4%, age 50 and older was 4.8%). 3. Race and ethnicity (Hispanic 5.6%, White, 7.4%, Black 5%, Asian 3.9%), 4, Sixty-four percent of all adults with major depression had severe impair ment (Box 9.1). In fact, the Global Burden of Disease has ranked depression as the second leading cause of disability worldwide and also a contributor of burden allocated to suicide and ischemic heart disease [2]. Although direct information on the prevalence and correlates of major depression does not exist for most countries, the available data reviewed below indicate that there is wide variability in prevalence estimates, but that other aspects of descriptive epidemiology (e.g., age-of- onset, persistence) are quite consistent acros countries. As such, a number of consistent socio- demographic correlates have also been found across countries [3]. Prevalence of DSM-IV/ CIDI major depressive episodes in the 18 coun- tries participating in the WMH surveys showed a lifetime prevalence of major depression among high income countries as listed in Box 9. 2 103 E. Messias et al. (eds.), Positive Psychiatry, Psychotherapy and Psychology, hups:f/doi.org/10.1007/978-3-030-33264-8_9104 F.EL-Gabalawi Box 9.2 France 21%, United States 19.2%, Netherlands 17.9%, New Zealand 17.8%, Belgium 14%, Spain 10.6%, Israel 10.2%, Germany 9.9%, Ttaly 9.9% and total was 14.6%. Among low- middle income countries lifetime prevalence of major depression showed the following Brazil 18.4%, Ukraine 14.6%, Colombia 13.3%, Lebanon 10.8, South Africa 9.8%, India 9%, and Mexico 8%. From the above survey, we see that major depression is a commonly occurring disorder in all countries where epidemiological surveys have been carried out; however, lifetime prevalence estimates of major depression vary widely across countries, with prevalence generally higher in high income versus low-middle income countries, and the age-of-onset distributions show consistent evidence for a wide age range of risk with median age-of-onset typically in early adulthood, while the course of major depression is often chronic- recurrent. Interestingly, women consistently across countries have lifetime risk of major depression roughly twice that of men; in the meantime, other socio-demographic correlates are far less consistent. Major depression is associ- ated with a wide range of indicators of impair ment and secondary morbidity, although some of these individual-level associations are stronger in high income than low-middle income countries. Historical Perspective of Depression Mental sufferings had been known to afflict humans since ancient times, and one of the com- mon pervasive conditions was known as Melancholia (depression). Until the Greco- Roman period, the condition was frequently attributed to demonic possession, for which many harsh measures, sich as exorcism ~ and possibly trepanation in prehistorical times - were used to rid the person of the evil spirit. However, during the fifth century B.C., Hippocrates had explained mental illnesses as resulting from imbalanced body fluids (the four humors were: yellow bile, black bile, phlegm, and blood) and that depres- sion was caused by excessive black bile in the spleen. In the seventeenth century, Robert Burton wrote his monumental work “Anatomy of Melancholy” in which he described multitudes of clinical symptoms of Melancholia from the suf- ferer’s perspective that seemed to resonate with our current understanding of depression, And interestingly he proposed Burton's six non- natural things that referred to such environmental factors as diet, alcohol, biological rhythms, and perturbations of the passion such as intense love. The moder conceptualization was intro- duced by the French psychiatrist Jean-Philippe Esquirol (1772-1840) who suggested that a pri- mary disturbance of mood might underlie many forms of depression and related paranoid psy- choses and the symptoms were the expression of the disorder of affections (affective disorders), the term was coined by the British psychiatrist Henry Maudsley (1835-1918). However, Emil Kracpelin (1856-1926) described manic depres- sion illness and he believed that endogenous affective disorders are somatically caused, yet he conceded that occurrence of psychogenic states of depression (due to loss or misfortune) is psy- chologically caused. It was Adolf Meyer (1866— 1950) who bridged the gap between psyche and soma, emphasized the individual personal his- tory and biographical factors, and introduced the term “psychobiology” emphasizing both biology and psychological causes of depression and other mental illnesses. So finally a conceptual shift from reductionist to pluralistic causation of depression was achieved [1] The Contemporary Etiological Models of Depression Etiological frameworks for depression included the biological models — including genetic and evolutionary, psychoanalytic, and psychody- namic behavioral, and cognitive models.9 Positive Interventions in Depression 105 Biological Models The biological model hypothesizes a connection between depletion or imbalance of biogenic amines such as catecholamine (norepinephrine), indoleamine (serotonin), and clinical depression. Current genetic evidence indicates a possible pre- disposing factor, however it is not known exactly what is inherited. An evolutionary model to explain depression proposes that our brains have evolved with a negative-event bias that overestimates threats as a strategy to avoid dan- gers and enhance survival chances Psychological Models Psychological models include aggression turned inward model (Abraham-Freud), object loss model (Freud-Bowlby), and a loss of self-esteem model. Cognitive model (Aaron Beck) hypothe- sizes that negative attributional styles such as thoughts of being helpless, unworthy, and useless can generate biased interpretations of life events. Learned helpless model (M. Seligman) proposes that depressive disposition can develop as a result of repeated past experiences of uncontrollable helplessness. The Role of Positive Psychiatry From the above discussion, it is evident that the etiological models of psychopathology of depres- sion are inconclusive, and there is not yet a clear genetic, iological, or psychological/social marker for depression, Moreover, the rapid rise and widespread use of antidepressant treatment of depression, based on the biological model of depression, has not been without controversy. Antidepressants are helpful in about half to two thirds of cases, especially with severe depression, however in most cases the effect is modest [4]; and in many cases especially in youth with major depression the antidepressant effect is close to a placebo effect. It is important to point out that clinical studies of antidepressants have primarily focused on reducing the symptoms of depression and not on a broader range of potential outcomes. (such as changes in everyday functions, cognitive abilities, quality of life, etc.) ‘An integrative model is most likely the approach to understand and treat depressive ill- nesses. Thus, positive psychiatry opens the pos- sibility that psychopathology is not the driving force to understand and treat depression, instead it emphasizes hope, optimism, character strength, and gratitude, among others, which can act as powerful protective factors against genetic vulnerability and precipitating stressors of depression ‘A study on the effectiveness of six internet- based Positive Psychology interventions con- cluded that two - using signature strengths in a new way and three good things — increased happi- ness and decreased depressive symptoms for 6 months. The other effective interventions The Gratitude Visit led to positive changes for 1 month [5]. In a large placebo-controlled clini- cal trial, where a quarter of the treated sample had depression, Positive Psychotherapy was shown to be an effective interdisciplinary approach with long-term symptom reduction [6] Finally, a meta-analysis looking at Positive Psychology Interventions concluded that they enhance wellbeing and decrease depressive symptoms and recommended clinicians incorpo- rate positive psychology techniques “particularly for treating clients who are depressed” [7] Clinical Application AR. isa 39-year-old white female attorney, mar- ried with one child. She was referred to outpa- tient treatment following her 3-week hospitalization on inpatient psychiatric unit for the treatment of severe recurrent major depres- sion with suicidal ideation, That was when she met her current outpatient psychiatrist in the year 2014. The psychiatrist learned that the hospital- ization was her third one, and that her history of clinical depression started during the year of 2011 and that she had been hospitalized approxi- mately once a year since the onset of the illness. Her hospitalizations were always ushered in by106 F.£L-Gabalawi sleep disturbance characterized by difficulty staying asleep, lack of motivation, decreased energy level, decreased appetite, and a sense of hopelessness and helplessness associated with fleeting suicidal ideation without intention or plan. She had never attempted suicide and con- sidered it to be unfair to her child and her sup- portive husband, She had been tried on many antidepressants at different times alone and sometimes in combination with mood stabilizers as augmenting agents with varying results. The last. medication regimen included Bupropion extended release, Lamotrigine, and Trazodone. In our first session, AR conveyed clearly that she had been tited of all those medications that seemed partially effective and frequently associ- ated with side effects. She was a strong believer in modern pharmacology and the power of medi- cation to correct the “chemical imbalance” that she believed it to be the cause of her depression, Her disappointment and disillusionment in the curing power of medications was incteasing. AR was convinced that her depression is hereditary, since her mother also suffered from major depres- sion and mother's response to antidepressant treatment was generally favorable. AR grew up in a small town in Pennsylvania, the oldest of three children, a sister 3 years younger, and a brother 5 years younger than her. Parents had frequent marital and financial prob- Jems due to father’s drinking problems and they were eventually divorced when AR was a junior in high school. She put all her energy in excelling in school and tried to help her mother raising the two younger siblings. Due to the difficult financial situation, she had to work part time while finish- ing college and went on to study law. She gradu- ated from law school with a large debt, yet was motivated to start working immediately to pay her Joans and to help her family financially. She joined a financial law firm in which the work envi- ronment was stressful and demanding, she worked Jong hours and always felt that she could not keep up with supervisor's expectations, She met her husband shortly after joining the law firm and had het only son who was 7 years old in 2014. AR described her husband as a caring and very sup- pottive person, Because of the stressful work and the long hours AR had to spend working, her hus- band, who worked in computer business, began to do most of his work from home, which made him available for child-care. She was the main bread winner of her family and always felt obligated to work hard to secure a decent life to her immedi- ate family; however, it was at the expense of the time spent with her husband and son. In addition to the hospitalizations, AR had occasional therapy sessions with different thera- pists and was seen by psychiatrists for medica- tion follow-ups; however, the outcome was not favorable since she continued to struggle with periods of depressive symptoms and three admissions. In reviewing the history of treatment and med- ication with AR, it became obvious that the focus of most treatment modalities had been on addressing her psychopathology and deficits and attempting to correct them. Whether the problem is a chemical-imbalance that needed to be cor rected by antidepressants and other somatic agents, or the problem is negative and dysfunc- tional thoughts that needed to be corrected through cognitive behavioral therapy sessions. Or the problem stemmed from her early forma- tive years when she was exposed to parents’ fre- quent discord due to father’s drinking problem that culminated into their divorce and father’s final abandonment of the family, which may have left AR with a deep feeling of poor self-worth and low self-esteem. Although those were legiti- mate issues that probably played a role in her depression, and convinced AR that she is some- how a deficient person, and she became even mote despondent that all those treatments had never achieved the goals of correcting the problems, It was clear that AR history of psychiatric evaluations and treatments, that was based on psychopathology and deficits will always recom- mend specific treatments, such as medications and individual therapy, while an evaluation that is based on the principles of positive psychiatry and wellness will produce different treatment recom- mendations that enhance the quality of life [8, 9] It seemed that another side of AR as a person was never explored or utilized and that a whole different9 Positive Interventions in Depression 107 mental state and way of thinking had to be adopted and tapped on, which could drastically change the direction of treatment and lead to a positive outcome, Positive Psychiatry Treatment Approach Assessment and Opening Sessions The initial phase of the treatment consisted of first, addressing certain beliefs about what it meant for AR to have depressive illness; second, involving the husband to some degree in her treatment; and finally, identifying positive traits and strength that she had. A discussion ensued regarding AR conviction of having a hereditary chemical imbalance, in which the psychiatrist explained that the term “chemical imbalance” could be misleading and inaccurate, and it is only a hypothesis, no chemicals are routinely mea- sured. The relationship between the chemicals (ncurotransmitters) and depression is very com- plex —discussion continued and itis not a causal relationship, meaning the presumed deficiency could be a cause or, in some cases, an effect of depression, also the effect of antidepressant on brain chemicals is most likely through several intermediary steps which are not fully under- stood. In terms of hereditary, the psychiatrist explained, it is not known what exactly that is inherited in addition, genes are not operating in isolation, genetics are in constant interaction with the internal and external environment, genes can affect behavior and behavior can affect genes expression (epigenetic). And it is better to con- ceive of hereditary as only a possible vulnerabil- ity that can be reduced through modifying stressful factors. Building a Support System The second step was (o involve the husband in her treatment, since her depression had affected the family and her stressful work had limited the time the family can spend together. AR agreed for the husband, who is a caring and supportive per- son, to join in every other session for the first year. Identifying and Using Character Strengths Identifying strengths was the third step, AR was encouraged to take VIA survey available online, in which she showed high character traits such as, kindness, judgment, and gratitude; she also showed a reasonable level of zest, a modest sense of hope, and a good level of love. She was encour- aged to be cognizant of her strength and to nur- ture her sense of hope and optimism during most of her daily activities, Addressing Stressors During several sessions that included her hus- band, and after long discussion regarding her stressful work environment, AR reached a deci- sion to quit her job and work as a part-time law- yer in a low-stress firm and to accept the less income yet she will enjoy more time with her husband and son and time for wellness. That also allowed her to volunteer a few hours per week as a legal advocate for mentally ill patients, an activ- ity she always wanted to do but could not due to her busy schedule in the past. The advocacy for patients made her highly conscious of the value and the power of optimism and hope that she began to instill in her clients. AR had been inter- ested in mindful-meditation in the past but could not find the time to practice, now she joined a group for mindful-meditation, and began to do her reading and meditation practices for 20 min daily. She added to her activities regular walking daily for half-hour, Within few months from adopting a positive psychiatry approach, sleep normalized, mood has improved significantly her outlook on life has changed positively. Medication regimen has been simplified, no mood stabilizers or sleep medication were required, and she only needed half of the dose of bupropion antidepressant, She had achieved a108 F.£L-Gabalawi remission for longer than 2 years and most importantly, her quality of life and well-being have been enhanced, References 1. Akiskal H. Mood disorders: introduction and over- view. In: comprehensive texthook of psychiatry. Baltimore: Williams and Wilkins; 1995. Ferari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, Murray CIL, et al. 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