INTRODUCTION TO DEPRESSION

Depression is a common and serious medical illness that negatively affects how you feel, the
way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of
sadness and/or a loss of interest in activities you once enjoyed. It can lead to a variety of
emotional and physical problems and can decrease your ability to function at work and at home.

Depression symptoms can vary from mild to severe and can include:

● Feeling sad or having a depressed mood

● Loss of interest or pleasure in activities once enjoyed
● Changes in appetite — weight loss or gain unrelated to dieting
● Trouble sleeping or sleeping too much
● Loss of energy or increased fatigue
● Increase in purposeless physical activity (e.g., inability to sit still, pacing, handwringing)
or slowed movements or speech (these actions must be severe enough to be observable by
others)
● Feeling worthless or guilty
● Difficulty thinking, concentrating or making decisions
● Thoughts of death or suicide

Symptoms must last at least two weeks and must represent a change in your previous level of
functioning for a diagnosis of depression.

Also, medical conditions (e.g., thyroid problems, a brain tumor or vitamin deficiency) can mimic
symptoms of depression so it is important to rule out general medical causes.

Depression affects an estimated one in 15 adults (6.7%) in any given year. And one in six people
(16.6%) will experience depression at some time in their life. Depression can occur at any time,
but on average, first appears during the late teens to mid-20s. Women are more likely than men
to experience depression. Some studies show that one-third of women will experience a major
depressive episode in their lifetime. There is a high degree of heritability (approximately 40%)
when first-degree relatives (parents/children/siblings) have depression.

Beck developed a cognitive explanation of depression which has three components: a) cognitive
bias; b) negative self-schemas; c) the negative triad.

a) Cognitive Bias

Beck found that depressed people are more likely to focus on the negative aspects of a situation,
while ignoring the positives. They are prone to distorting and misinterpreting information, a
process known as cognitive bias.

Beck detailed numerous cognitive biases, two of which include: over-generalisations and
catastrophising. For example, a depressed person may make over-generalisations, where they
make a sweeping conclusion based on a single incident, for example: ‘I’ve failed one end of unit
test and therefore I’m going to fail ALL of my AS exams!’ Alternatively, a depressed person
may experience catastrophising, where they exaggerate a minor setback and believe that it’s a
complete disaster, for example: ‘I’ve failed one end of unit test and therefore I am never going to
study at University or get a good job!’

b) Negative self-schemas

A schema is a ‘package’ of knowledge, which stores information and ideas about our self and the
world around us. These schemas are developed during childhood and according to Beck,
depressed people possess negative self-schemas, which may come from negative experiences, for
example criticism, from parents, peers or even teachers.

A person with a negative self-schema is likely to interpret information about themselves in a

negative way, which could lead to cognitive biases, such as those outlined above.

c) The negative triad

Beck claimed that cognitive biases and negative self-schemas maintain the negative triad, a
negative and irrational view of ourselves, our future and the world around us. For sufferers of
depression, these thoughts occur automatically and are symptomatic of depressed people.
The negative triad (pictured below) demonstrates these three components, including:

The self – ‘nobody loves me.’

The world – ‘the world is an unfair place.’
The future – ‘I will always be a failure.’

TYPES OF DEPRESSION

The four most common types of depression are major depression, persistent depressive disorder
(formerly known as dysthymia), bipolar disorder, and seasonal affective disorder.

Major depression- The classic depression type, major depression is a state where a dark mood is
all-consuming and one loses interest in activities, even ones that are usually pleasurable.
Symptoms of this type of depression include trouble sleeping, changes in appetite or weight, loss
of energy, and feeling worthless. Thoughts of death or suicide may occur. It is usually treated
with psychotherapy and medication. For some people with severe depression that isn't alleviated
with psychotherapy or antidepressant medications, electroconvulsive therapy may be effective.

Persistent depressive disorder- Formerly called "dysthymia," this type of depression refers to low
mood that has lasted for at least two years but may not reach the intensity of major depression.
Many people with this type of depression type are able to function day to day, but feel low or
joyless much of the time. Other depressive symptoms may include appetite and sleep changes,
low energy, low self-esteem, or hopelessness.

Bipolar disorder- People with bipolar disorder—once known as manic-depressive disease—have

episodes of depression. But they also go through periods of unusually high energy or activity.
Manic symptoms look like the opposite of depression symptoms: grandiose ideas, unrealistically
high self-esteem, decreased need for sleep, thoughts and activity at higher speed, and ramped-up
pursuit of pleasure including sex sprees, overspending, and risk taking. Being manic can feel
great, but it doesn't last long, can lead to self-destructive behavior, and is usually followed by a
period of depression. Medications for bipolar disorder are different from those given for other
depression types, but can be very effective at stabilizing a person's mood.

Seasonal affective disorder (SAD)- This type of depression emerges as days get shorter in the
fall and winter. The mood change may result from alterations in the body's natural daily rhythms,
in the eyes' sensitivity to light, or in how chemical messengers like serotonin and melatonin
function. The leading treatment is light therapy, which involves daily sessions sitting close to an
especially intense light source. The usual treatments for depression, such as psychotherapy and
medication, may also be effective.

Depression types unique to women

Although women are at higher risk for general depression, they are also at risk for two different
depression types that are influenced by reproductive hormones—perinatal depression and
premenstrual dysphoric disorder (PMDD).

1. Perinatal depression. This type of depression includes major and minor depressive
episodes that occur during pregnancy or in the first 12 months after delivery (also known
as postpartum depression). Perinatal depression affects up to one in seven women who
give birth and can have devastating effects on the women, their infants, and their
families. Treatment includes counseling and medication.
2. PMDD. This type of depression is a severe form of premenstrual syndrome, or PMS.
Symptoms of PMDD usually begin shortly after ovulation and end once menstruation
starts. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and
sertraline (Zoloft), may reduce symptoms.
THEORETICAL APPROACHES TO DEPRESSION

● Psychological theories of depression focus on cognition and behaviour in regulating

mood. This approach stresses the influence of our past experiences (nurture) in shaping
our thought patterns that can result in depressive symptoms. Past experiences can cause
people to develop negative schemas – biased patterns of thinking about ourselves, others
and the world around us, maintaining psychological distress. The psychological theories
of depression are supported by the effectiveness of therapies like CBT, which aim to
challenge negative schemas in treating depressive symptoms.
● Biological theories of depression identify biological factors like genes, brain structure,
and the function of neurotransmitters and hormones as the cause of depression.
Biological theories stress the influence of nature in causing depression.
● Depletion of neurotransmitters: the monoamine theory of depression. The monoamine
theory of depression predicts that depression results from reduced levels of monoamines
like serotonin. Serotonin is a neurotransmitter. It functions as a messenger in the brain
and is associated with regulating functions that are affected in depressed individuals, like
mood and sleep. Based on this theory, antidepressants (SSRIs) have been developed and
shown to reduce depressive symptoms in some patients. A significant criticism of
antidepressants is that their effectiveness is not much higher than a placebo, and they can
cause serious side effects in some patients. However, antidepressant treatment can be
more accessible than therapy for many patients.
● Behavioural theory of depression proposes that depressive symptoms are perpetuated by
avoidance behaviour. Depressed individuals will often avoid potentially rewarding
activities and become withdrawn, making their symptoms worse. One way this approach
influences treatment is by informing behavioural interventions like Behavioural
Activation, which encourages clients to schedule pleasant activities. Rather than focusing
on changing one's thoughts and feelings, this approach attempts to increase the amount of
positive experiences in one's daily life, which can in turn influence one's mental state.
● The social rank theory of depression. Stevens and Price developed the social rank theory
of depression. They proposed depression is an evolutionary adaptation; it allows
individuals that fell to lower social ranks to accept their position. Depressive symptoms
 prevent weaker individuals from engaging in conflicts that threaten their survival.
Accepting one's lower position allows people to save resources instead of spending
energy on conflicts and trying to regain a lost social rank, which could result in greater
losses upon defeat.
● Cognitive theory of depression- The ABC Model of clinical depression proposed by Ellis
(1957) argues that distorted irrational beliefs (B) cause distress, forming as a response to
an activating event (A). According to this model, depression is the consequence (C) of
irrational beliefs. Irrational beliefs can form automatically, and we may not even realise
that we hold them. Irrational beliefs can include catastrophising, 'black and white'
thinking and personalising. Catastrophising occurs when we interpret a difficult event as
worse than it is.Catastrophising occurs when we interpret a difficult event as worse than
it is. Since our cognition and behaviour can be influenced by outside events or our own
physiology, the ABC model supports the idea that we don't always have free will when
we make decisions about our behaviour. This puts into question how responsible, people
experiencing cognitive distortions are for their behaviour.
● Beck's negative cognitive triad- Aaron Beck (1967) proposed three main types of beliefs
that maintain depressive symptoms. These include negative thoughts and beliefs about
the self, the world, and the future. The three types of negative beliefs can be mutually
reinforcing; for example, a negative belief about the world can strengthen a negative
belief about the future.
● Seligman's negative attributions- According to Seligman, depression is an outcome of
learned helplessness. Depressed individuals feel like no matter what they do, they cannot
control the negative events in their life. Learned helplessness is maintained by believing
that we are the cause of the failure; we cannot change the cause, it's stable, and the failure
is global. We will always fail in every situation. By challenging these thoughts,
individuals can learn to feel more in control of their life and reduce the sense of learnt
helplessness associated with depressive symptoms.
Etiology

Defective mood regulation by the brain, genetic vulnerability, stressful life events, drugs, and

medical conditions are all possible causes of depression. It’s also thought that some of these

factors work together to cause depression.

Biological Causal Factors

Mood can be affected by a range of disorders and medicines, which can lead to depression.

Researchers looking for a biological explanation for unipolar illnesses have investigated a variety

of elements.

Genetic Factors: According to family studies, the prevalence of depression is two to three times

higher among blood relatives of those with clinically diagnosed unipolar depression than it is in

the general population. Twin studies which can provide much more conclusive evidence of

genetic influences on a disorder, also suggest a moderate genetic contribution to Depression.

Neurophysiological factors: People with depression have reduced activity in the left hemisphere

of the brain’s prefrontal regions. Damage to the left side, but not the right, anterior prefrontal

cortex has also been linked to depression in studies.

Sleep and other biological rhythms: Patients who are depressed often show one or more of a

variety of sleep problems, ranging from early morning awakening, periodic awakening during

the night (poor sleep maintenance), and, for some, difficulty falling asleep. Research has also

found some abnormalities in all of these rhythms in patients with depression.

Neurochemical Factors: Depression can also be caused by changes in the delicate balance or

depletion of neurotransmitter molecules (such as serotonin and norepinephrine) that regulate and

modulate the activity of the brain’s nerve cells. This depletion could come about through
impaired synthesis of these neurotransmitters in the presynaptic neuron, through increased

degradation of the neurotransmitters once they were released into the synapse, or through altered

functioning of postsynaptic receptors.

Sex differences: For a small minority of women who are already at high risk, hormonal

fluctuations may trigger depressive episodes, possibly by causing changes in the normal

processes that regulate neurotransmitter systems

Psychological Causal Factors

Thinking: Depression is linked to a variety of thought habits:

● Overemphasizing the negative

● Assuming responsibility for terrible occurrences but not for good events are examples of

these thought tendencies.

● Having rigid guidelines for how one should act.

● Believing that you know what people are thinking about you and that they are negatively

thinking about you.

Loss: Loss is a common occurrence in people’s lives, and this can lead to despair. The loss of a

loved one through bereavement or separation, the loss of a job, the loss of a friendship, the loss

of a promotion, the loss of face, the loss of support, and so on are all examples of loss.

Sense of Failure: Some people may place a high value on attaining specific objectives, such as

receiving “As” on tests, landing a specific job, making a certain amount of profit from a business

venture, or finding a life mate. If they are unable to reach those goals for some reason, they may

believe that they have failed in some way, and it is this sense of failure that can sometimes lead

to depression.
Stress: Depression can be brought on by a series of stressful life experiences. Unemployment,

financial worries, substantial difficulties with a spouse, parents, or children, physical disease, and

major changes in life circumstances are all examples of stressful situations.

Lack of Social Support and Social-Skills Deficits: People who are lonely, socially isolated, or

lacking social support are more vulnerable to becoming depressed and that individuals with

depression have smaller and less supportive social networks, which tends to precede the onset of

depression.

The Effects of Depression on Others: Depressive behavior can, and over time frequently does,

elicit negative feelings and rejection in other people, including strangers, roommates, and

spouses. Ultimately a downwardly spiraling relationship usually results, making the person with

depression feel worse (Joiner, 2002).

Marriage and Family Life: A significant proportion of couples experiencing marital distress have

at least one partner with clinical depression. One possibility is that criticism perturbs some of

the neural circuitry that underlies depression. Even after full recovery, criticism may still be a

powerful trigger for those who are vulnerable to depression. Parental depression puts children at

high risk for many problems, but especially for depression.

Treatment Approaches

● Selective Inhibitors of Serotonin Recovery (SSRIs): These medicines are considered safer

than other types of antidepressants and usually produce fewer side effects. Blocks

serotonin reuptake. CitalOPRAM (Celexa), escitalOPRAM (Lexapro), fluoxetine

(Prozac), vilazodone, sertraline (Zoloft) are a few examples.

● Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Blocks serotonin and

norepinephrine reuptake. For instance, duloxetine (cymbalta), venlafaxine (effexor XR)

etc.

● Atypical Antidepressants: These drugs do not fit into any other category of antidepressant

drugs properly. Bupropion, mirtazapine, nefazodone etc.

● Tricyclic Antidepressants: Medications, such as imipramine (Tofranil) etc. can be very

effective. Thus, tricyclics are not usually prescribed unless first tried to improve an SSRI.

● Monoamine oxidase inhibitors (MAOIs): A MAO-I can be prescribed, for example, when

other drugs have not worked because they may have severe side effects. These include

tranylcypromine (parnate), phenelzine (Nardil) etc. SSRIs cannot be combined with these

medications.

● Interpersonal psychotherapy (IPT): Short-term psychodynamic therapy. Focuses on

resolving problems in current interpersonal relationships, which often trigger depressive

episodes, and help in forming new interpersonal relationships.

● Cognitive therapy: Monitor and identify automatic thoughts. Replacing negative thoughts

with more neutral or positive thoughts.

● Mindfulness-based cognitive therapy (MBCT): Strategies, including meditation, to

prevent relapse.

● Behavioral activation (BA) therapy: Increase participation in positively reinforcing

activities to disrupt spiral of depression, withdrawal, and avoidance.

● Light Therapy: Exposure to artificial light that mimics natural light, to treat seasonal

affective disorder that is sensitive to weather and lighting conditions.

Introduction to BDI-II

The original BDI, first published in 1961, consisted of twenty-one questions about how

the subject has been feeling in the last week. Each question had a set of at least four possible

responses

According to Beck's publisher, 'When Beck began studying depression in the 1950s, the

prevailing psychoanalytic theory attributed the syndrome to inverted hostility against the self.'

By contrast, the BDI was developed in a novel way for its time; by collating patients' verbatim

descriptions of their symptoms and then using these to structure a scale which could reflect the

intensity or severity of a given symptom.

Beck drew attention to the importance of "negative cognitions" described as sustained,

inaccurate, and often intrusive negative thoughts about the self. In his view, it was the case that

these cognitions caused depression, rather than being generated by depression.

Beck developed a triad of negative cognitions about the world, the future, and the self, which

play a major role in depression. An example of the triad in action taken from Brown (1995) is the

case of a student obtaining poor exam results:

● The student has negative thoughts about the world, so he may come to believe he does

not enjoy the class.

● The student has negative thoughts about his future because he thinks he may not pass the

class.

● The student has negative thoughts about himself, as he may feel he does not deserve to be

in college

The BDI-II was a 1996 revision of the BDI, developed in response to the American

Psychiatric Association's publication of the Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition, which changed many of the diagnostic criteria for Major Depressive

Disorder.

Items involving changes in body image, hypochondriasis, and difficulty working were

replaced. Also, sleep loss and appetite loss items were revised to assess both increases and

decreases in sleep and appetite. All but three of the items were reworded; only the items dealing

with feelings of being punished, thoughts about suicide, and interest in sex remained the same.

Finally, participants were asked to rate how they have been feeling for the past two weeks, as

opposed to the past week as in the original BDI.

The BDI-II contains 21 items on a 4-point scale from 0 (symptom absent) to 3 (severe

symptoms). The 21 depressive symptoms and attitudes chosen by Beck et al. (1961) for inclusion

in the BDI were based on the verbal descriptions by patients and were not selected to reflect any

particular theory of depression. These items were (1) Mood, (2) Pessimism, (3) Sense of Failure,

(4) Self-Dissatisfaction (anhedonia), (5) Guilt, (6) Punishment, (7) Self-Dislike, (8) Self-

Accusations, (9) Suicidal Ideas, (10) Crying, (11) Irritability, (12) Social Withdrawal, (13)

Indecisiveness, (14) Body Image Change, (15) Work Difficulty, (16) Insomnia, (17) Fatigability,

(18) Loss of Appetite, (19) Weight Loss, (20) Somatic Preoccupation, and (21) Loss of Libido.

So in summary, in the revised version the respondent must recall, based on the previous two

weeks, the relevance of each statement relating to: sadness, pessimism, sense of failure, loss of

pleasure, guilt, expectation of punishment, dislike of self, self-accusation, suicidal ideation,

episodes of crying, irritability, social withdrawal, indecisiveness, worthlessness, loss of energy,

insomnia, irritability, loss of appetite, preoccupation, fatigue, and loss of interest in sex (Beck &

Steer, 1988).
Plan

To measure the severity of depression in adults and adolescents aged 13 years and older.

Materials

1. Beck Depression Inventory-II with 21 statements

2. Norms

3. Writing material

Procedure

The subject is seated comfortably. The subject is given a copy of Beck’s Depression Inventory

and is asked to read each statement carefully and is asked to respond to each statement by

circling the statement that best describes the subject. The subject’s responses need to be scored

and interpreted.

Scoring

Each of the 21 items corresponding to a symptom of depression is summed to give a single score

for the Beck Depression Inventory-II (BDI-II). There is a four-point scale for each item ranging

from 0 to 3. On two items (16 and 18) there are seven options to indicate either an increase or

decrease of appetite and sleep. Cut-off score guidelines for the BDI-II are given with the

recommendation that thresholds be adjusted based on the characteristics of the sample, and the

purpose for use of the BDI-II. Total score of 0–13 is considered a minimal range, 14–19 is mild,

20–28 is moderate, and 29–63 is severe.

Validity

One measure of an instrument's usefulness is to see how closely it agrees with another similar

instrument that has been validated against information from a clinical interview by a trained

clinician. In this respect, the BDI-II is positively correlated with the Hamilton Depression Rating

Scale with a Pearson r of 0.71, showing good agreement.

Reliability

The test was also shown to have a high one-week test–retest reliability (Pearson r =0.93),

suggesting that it was not overly sensitive to daily variations in mood. The test also has high

internal consistency (α=.91).

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Hammen (Eds.), Handbook of depression and its treatment (2nd ed.). Guilford Press.

Seligman, M. E. (1973). Fall into helplessness. Psychology today, 7(1), 43-48.

Seligman, M. E. (1974). Depression and learned helplessness. John Wiley & Sons.

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depression-types

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