July 6, 2007
This paper develops a framework around the history of major depressive disorder. It examines the history and theories of this disease, also known as unipolar disorder. It develops a theory of the implications for clients, client's families, employers and counsellors to create an understanding of the disorder, to better understand the physiological responses and psychosocial consequences of this mental health issue. It examines the impact of depression and demonstrates the necessity of identifying and treating it early. The conclusion examines ideas for further research and the impact of technology on this field including research in the areas of cognitive therapy, technology and early identification.
[ Introduction | Theoretical Perspectives | Literature Review: Biological Factors; Psychosocial Factors
Implications: for Clients & Families; Counselling and Counsellors | References ]
Major depressive disorder is one of the most common mood disorders (Pezawas, 2005; Pinel, 2007; Sigelman & Rider, 2006). Diagnostic and statistical manual of mental disorders (DSMV-IV, 1994 ) provides a quantitative analysis for major depressive disorder and includes a check list with a weighting factor. Pinel (2007) refers to major depressive disorder as unipolar disorder to differentiate it from bipolar disorder, in which the patient experiences activities of extreme overconfidence, impulsivity, distractibility, and high energy, as well as bouts of depression.
The consequences of unipolar disorder leads to an impact on the social, emotional and socioeconomic lives of clients. This paper strives to create a modern response to an age-old disorder, based on the latest research from biology, psychology and sociological sources. It points to the importance of the counsellor to have a holistic understanding and an integrative approach to the treatment of this disorder.
Fink et al (2007) and Shorter (2006). call for a renaming of this disorder for the publication of DSMV-V by melancholia. This will differentiate the disorder from its various subgroups and will aid in identification and treatment of the disorder. It is clearly identifiable by its psychcomotor disturbance, psychotic and non-psychotic disorders and neuroendocrine markers. To enable more disorder-specific research,
Treatment in the past 60 years has been wide and varied and has included pharmocuetical, psychotherapy, and electroconvulsive therapy (ECT) . Taylor (2005) finds ECT a useful and underused therapy on carefully selected patients, i.e. those resistant to drug therapy, the elderly, or during pregnancy.
Treatments for depression in the past have ranged from physical treatments for apparent physiological disturbances such as purging, bleeding and blistering, to surgery to remove the theoretical cause of the disease.
Galton’s heritability of families and twins in the 1860’s opened the door to more scientific explorations of this disorder. Freud’s psychosocial theories developed from his 1895 work on synapses and neuroplasticity (Doidge, 2007), Freud tied his research to his early work on neurology (Doidge, 2007). With Philippe Pinel’s more humane approach, rather than locking away the mentally ill (Making the World, 2004), theorists recognized social or psychological distresses, and studies of temperament, body types and emotional patterns in the 1940’s demanded further biopsychosocial research (Friedman & Schustack 2006). Eysenck’s brain-based model or personality in the 1960’s, evolutionary personality psychology in the 1990’s (Friedman & Schustack 2006), and the study of genetic bases of individual behaviour patterns in the present have led to a wide array of attitudes, etiologies and treatments for depression (Pinel, 2007; Sigelman & Rider, 2006).
Freud felt that depression is a reaction to inner guilt and self-criticism, which can be traced back to early childhood loss (Friedman & Schustack 2006), Currently, Doidge’s work (2007) supports Freud’s connection between the physiological, the psychological and the emotional consequences of this disorder. Doidge (2007) examines the plasticity of the brain and, how, through psychotherapy, cites research to demonstrate how the amount of flow of blood in the brain can be changed in the early years and brain cells can be rewired in the prefrontal cortex to rewire the brain’s circuitry and improve the biopschyosocial reaction to stress. He advocates for the counsellor to help the client reframe her thinking to move forward. Attitude and perception is formed in early years, but can be changed in adulthood.
Physical symptoms of depression include fatigue, sleep issues, tremours, cognitive deficits and can be masked by other physical, social and emotional issues. Depression is a serious, life-debilitating mental health issue. It is a silent disease which crosses developmental ages and stages (Straugh, 2003; Sigelman & Rider, 2006), but becomes more evident during the biological changes associated with adolescence. Straugh (2003) points to the research from the National Institute in Washington in which rates for major depression rise beginning in puberty. Interpersonal stress, establishing a sexual identity, in addition to hormone levels and biological reactions to stress, leading to a preponderance for stress reaction (Sigelman & Rider, 2006) . It is at this stage that the brain is developing brain cells and refining brain structures, creating and pruning dendrites in preparation for adulthood (Nunley, 2003).
Cells in the central nervous system control mood, eating, sleep, pain and thinking. When a person is under stress, their body reacts with the fight or flight response and, like adrenaline, the body becomes flooded with serotonin (Hariri et al, 2002; Nunley, 2003). Neurotransmitters are responsible for sending signals across the synapses between cells and throughout the body. Under stress the synapse is flooded with serotonin and noradrenalin as the organism pumps in these chemicals to aid in its response. Treatment for depression included three types of anti-depressants: tricyclics, monoamine oxidase inhibitors and tretracyclics (selective serotonin-reuptake inhibitors or SSRIs). These drugs increased the amount of norepinephrine and serotonins, which increased serotonic transmission. They provide the physician with drugs that not only have an effect on physical symptoms in patients but affect emotional changes to perceptions of self-esteem, fear of failure, excessive sensitivity to criticism, and the inability to experience pleasure (Bosker et al, 2004; Pinel, 2007).
Current research, with the help of functional Magnetic Resonance Imaging (fMRI), demonstrates that as the brain cells attempts to communicate with each other, putting chemicals into the synapses, neurotransmitters, such as dopamine or serotonin, trigger the neighbouring cells to fire. The body can re-use these chemicals and the re-uptake mechanisms would allow absorption of the serotonins. The new drugs such as the norepinephrines Paxil or Zoloft, shut off the re-uptake inhibitors allowing serotonin levels to return to normal neuronal firing rates. Selective serotonin reuptake inhibitors (SSRIs) Only 25% of patients (Pinel, 2007) are helped with monoamine agonists and this theory supports the necessity of counseling interventions (Szigethy et al, 2002).
Historically patients have been subjected to various drugs such as monoamine inhibitors (Pinel, 2007; Bosker et al, 2004). Some of these drugs have been shown to increase the risk of strokes (Pinel, 2007). Other symptoms include Blurred vision, hallucinations, hypertension, dizziness, fatigue, nausea, and anxiety.
Stress can create changes in the brain that have a lifelong impact, and leave the patient without critical brain cell functioning (Doidge, 2007). The drugs target the dysfunctioning monamine neurotransmitter circuits in the central nervous system, serotonin and norepinephrine, but frequently patients do not respond until 3-5 weeks of regular use. Neremoff (2002) found that after 6-8 weeks, only 35-45% of patients managed to reach premorbid levels of functioning. The balance of patients did not respond or failed to respond adequately to chemical treatment.
During depression autonomic functioning is impaired and sympathetic arousal contributes to increase cardiovascular risks (Karavidas et al, 2007). Biofeedback was been shown to be effective in relieving this symptom. The therapeutic benefits of exercise (Balkin et al, 2007) continue to reflect a complex relationship between wellness and the physiological benefits of a holistic therapy. This study questions whether participating in exercise is evidence of a cure, or a benefit of choosing to become involved in these studies.
Depression not attributable to a particular cause is called endogenous depression. Pezawas et al, (2005) and Hariri et al, (2002) identified a functional polymorphism in the human serotonin transporter that appears in cell activity during depression. Studies have found links between physiological responses in the prefrontal cortex and the amygdala. There are ranges from underactivity of monoamine oxidase inhibitors and norepinephrine. This, in conjunction with individual tempermental differences, creates the difference between normal and abnormal behaviour. Some patients in autopsy indicate a proliferation of serotonin receptors. Paul et al, (2004) finds an association between folic acid deficiency, but cites inconsistencies in methods of measurement and findings appear inconclusive. Folic acid and the relationship between mood disorders has been identified as significant factor, but more research is required.
Pinel (2007) supports the theory that brain damage is an underlying cause or effect of depression, which can be measured quite clearly. Depressed patients cannot experience pleasure (anhedonia), as evidenced in the mesotelencephalic dopamine system. Genetics add to the susceptibility of a patient and their ability to face depression, with stressful life events triggering a bout with depression. Pezawas et al, (2005) found a genetic susceptibility demonstrated by neuroimaging with subjects demonstrating anxiety, and emotional reactivity in response to fear.
Kendler, et al (1995) estimated heritability factors, based on twin research, at 41 to 46%. Pezawas et al, (2005) reported a 70% heritability factor. Researchers cannot agree, due to the inability to separate biological factors from psychosocial factors.
As the brain creates dopamine, in response to pleasure, the brain, if faced with excessive production of mimicked dopamine from the alcohol or drugs, naturally decreases its production and the patient has difficulty seeking the same pleasurable feeling with the same amounts of artificial sources. The brain removes and reduces dopamine receptor sites. Alcohol and drug abuse contribute chemically to the effects of depression. Not only does the patient need increasing amounts of unnatural substances to feel pleasure, but reduces available receptors (Nunley, 2003).
Ill-health is another factor in a diagnosis of depression. Akechi, et al, (2001) found that 12.8% of referred cancer patients were diagnosed with major depression. 51.4 % had suicidal ideations. Biological, psychological, and social factors influence depression. Morley et al, (2004) advises against genetic screening due to the ineffectiveness of such measures. Many variables influence the development of unipolar disorder.
As with all medications, there can be side effects which preclude the patient from following doctor’s orders. Nausea, difficulties falling asleep, feeling sleepy or dizzy, yawning, diarrhea, constipation, increased sweating and sexual disturbances. Other reported side effects include unspecific symptoms like a clogged or running nose, decreased appetite, fatigue and a mild fever (iCan, 2007).
Depression is categorized by its etiology: medical conditions, postpartum depression, premenstrual depression, and seasonal affective disorder, for example, all result in depressive symptoms. Reactive depression is the response to an extremely negative experience: bereavement, job loss, miscarriage (Scheidt et al, 2007), rape. Depression can be brought on by an extreme response to life’s normal passages (moving, a new job, childbirth, bereavement). Depression can occur during the entire adult stage of life, but it is more frequently diagnosed in early adulthood with new challenges faced by those just beginning their path to adulthood and less frequently in late adulthood as a healthy adult adjusts to life in society (Sigelman & Rider, 2006).
The client is said to have this disorder if he or she is reporting five of the following symptoms, including the first and second. Depressed mood, greatly decreased interest or pleasure in activities, significant weight changes, insomnia or oversleeping, psychomotor agitation or sluggishness, fatigue and loss of energy, feelings of worthlessness or guilt, concentration issues or indecisiveness, suicidal ideations or attempts. It is characterized by persistent symptoms, experienced over two week, as differentiated by mild feelings of depression, which do not affect daily life, social interactions, work or personal hygiene (American Psychiatric Association, 1994)..
Kagan’s work (CBC, 2007) included the study children. He found that with novelty they will demonstrate cautiousness. He concluded that temperamental traits cause a reaction to new experiences demonstrating introversion or extrovert tendencies. The amygdala reacts to unexpected and ambiguous events and the client associates this with fear. He classified 60 % of the children he studied as high reactive, the other 40% as low reactive. Low reactives didn’t move, cry or generate the same amount of stress symptoms in response to new things. He found that less than 5% changed temperaments. Being classified as high reactive doesn’t guarantee that you’ll be a fearful, high risk adolescent but it demonstrates a preponderance for social reactions and the powerful inbuilt need to protect oneself in society.
Unfortunately, media reports abound with drug warnings, especially for teenagers, regarding the risks of taking such chemotherapies (U.S. F.D.A., 2004) and the consequences of abuse. Clients should be monitored since side effects associated with taking more than the recommended doses of SSRIs, for example, could include dizziness, shaking, agitation, drowsiness, reduced consciousness, seizures, heart racing, slowed breathing, and vomiting.
Depression is a disorder that strikes all socioeconomic stratas. Somers, et al (2006) in a review of the literature on anxiety disorders found that between 1980 and 2004 4.2 % of the population in Italy, 9.2 % in Korea, 28.7 % in Switzerland. Mulholland, (2005) cites a rate of depression of 8 per cent for men and 12 per cent for women in the U.K., while stating that another unidentified group of patients likely suffer in silence. Reaction to stress can be seen in the preponderance of those who commit murder-suicides (Kumar et al, 2006).
Workplace stress (Jilks, 2003), unemployment (Comino et al, 2007) and stressful life events (Kendler, 1997) are factors in the presentation of clients with unipolar depression. Suicide rates in Canada soared during the depression and suicide rates for males are about four times that for males. (Statistics Canada, 2005). Gender statistics found that more women are diagnosed and treated with this disorder. U.K. statistics show that about 80% of women who have received treatment for depression commit suicide (Mulholland, 2005). Only 50% of men fall into this category. Of the men who committed suicide, two-thirds demonstrated themselves mentally ill and 20% have alcoholism. The Canadian Mental Health Association (CMHA, 2006) finds a prevalence higher amongst, for example, Inuit, Native groups, particular age groups. Suicide accounts for 24 % of deaths of 15-24 year old and 16 % of 16 – 44 year olds. 73% of hospital admissions for attempted suicide are for 15 – 24 year olds. (CMHA, 2006)
Likierman (2003) examines postpartum depression and cites such factors as extreme financial, social and emotional issues during this stage of life, especially in the event of marital difficulties. In the event of such a debilitating disorder, which has a profound effect on the whole person, an integrative approach is to be addressed.
Avis (2003), in an attempt to determine the answer to the question of depression as it relates to perimenopause and menopause concluded that these factors do not cause depression. The stage of life in which a woman finds herself: empty-nest syndrome (or adult children returning home), ailing parents, and other life passages, can cause a depressive reaction unrelated to the changing hormones (estrogen and progesterone). She felt that most studies examined patients, rather than the general population, and many women do not suffer from depression during menopause. Further examination found that the length of menopause and more than 27 months of symptoms (hot flashes, night sweats and menstrual problems) resulted in an increased likelihood of depression due to the effects of the symptoms, rather than the condition itself.
Depression can be related to particular medical interventions, such as cancer treatments (Capuron, et al, 2002) and open-heart surgery, and brain injury. The elderly are at risk due to life-changing circumstances, ill health and as a reaction to changes in environmental circumstances (Alexopoulos, 2005). The Mood Disorders Association of Ontario (n.d.) states that depression accounts for 30% of all disability in large companies in Canada. Employers are becoming more aware of not only the cost to health care system but of the loss of productivity. Employers are developing employee management plans to assist the employee in recovery and returning to work (Jilks, 2003; Nease et al, 2003; Ottawa-Carleton District School Board, 2006; Ottawa Carleton Elementary Teacher’s Federation, 2000; Trillium Lakelands District School Board, 2007). This trend continues as the loss of productivity in employees becomes increasingly significant.
Pharmaceutical responses by the medical profession do not address the underlying
causes of this disorder. Freud’s dream therapy can be helpful in assisting
the patient in understanding her subconscious mind. Doidge (2007) cites work
on recurring dreams, which contain memory fragments buried in the brain. Educating
the client, providing research information, literature, and expectations regarding
the progression of the disorder helps empower them to assuage fears of what
is normal and what can be expected.
Nemeroff & Owens (2002) reports that the results are achieved more quickly with ECT than with antidepressants. It is a treatment that is still being debated, with biases against it preventing some from making it a treatment choice, despite changed in the method of delivery in current practice. Tecoult & Nathan (2001) found complications in 68% of patients administered ECT . Psychosurgery in extreme cases is still one treatment method for those for whom other treatments have proven ineffective (Ridout, 2007).
Implications for Clients and Their Families
Families with a history of suicide and drug abuse need to be vigilant and seek medical help for teenagers who are at risk. Clients, their families and their advocates are wise to watch for signs of depression and explore the options for treatment. Many resources are available online, particularly. One company posts daily positive suggestions for improvement with practical daily reminders to take medications as prescribed and to seek counseling as required (iCan, 2007).
Many resources are available online, particularly. One drug manufacturer has created an on-line, interactive, self help community in which the patient takes weekly self-tests to determine their progress (Fig. 1). The company posts daily positive suggestions for improvement with practical daily reminders to take medications as prescribed and to seek counseling as required (iCan, 2007).
Figure 1. Results of depression self-rating tool by the author taken on-line June 17, 2007. (iCan, based on Zung et al, 1965.) 40 or above (the red line) indicates clinical depression.
Important choices in the repertoire of the counsellor include psychotherapy, group therapy, non-directive counseling, interpersonal therapy, psychodynamic therapy, exercise, diet, in an integrative cognitive-behaviour therapy approach (Likierman, 2003; Balkan, 2007). In order to formulate a plan for therapy and recovery the counsellor should involve family and provide support regarding potential suicidal ideations and take a complete biopsychosocial history. It is crucial that clients at risk be contacted on a regular basis. Referrals to health care professionals are important to deal with the biological impact of the disorder. Comino et al (2000) urges general practitioners to monitor unemployed patients.Implications for Community/Society
A silent disorder, often undiagnosed by the medical community (Nease et al, 20003) depression is preventable, if not treatable. All stakeholders need to become involved in the prevention and treatment of this disorder. The cost to society, in terms of health care. This disorder impacts the client, her social and work-related goals and her family.
Comino et al (2000) urges general practitioners to monitor unemployed patients. At the same time, workplace stress, including bullying by peers and bosses, is on the increase leading to environmental and emotional stress (Jilks, 2003). Often a patient's first medical contact is with the medical profession is as an employee who is referred through Employee Assistance Programs (EAP) or as a result of using sick leave. Clients who do not follow up with costly psychological support, limited by most insurance carriers, or do not follow doctor's medication recommendations result in the perception that medication or psychotherapy does not work.
There are many stakeholders in the healing profession, with vested interests in drug therapy, counselling, and the cost to public health. As our understanding of depression, with increasingly scientific and objective research being published, in conjunction with modern treatments, humankind can learn to recognize and prevent, rather than cure, this disorder. Workplace stress, the resulting emotional issues, and the use of the health care system, is on the increase resulting in lost productivity. This is of concern to many employers (Jilks, 2003). Prevention, rather than cure will help those avoid depression.
It would appear that vigilance on the part of family, friends, counsellors and the busy medical profession is warranted. With the pressing concerns of daily life, and our responses to stress is documented through fMRI and positron emission tomography. It is morally imperative that the mental health community supports and works with other professionals in an holistic approach to therapy.
Further research in the area of lost productivity due to clients taking medications unreliably or not following prescription recommendations, or discontinuing their medications, could contribute to the low success rates in depression patients. Studies tend to examine those already seeking medical therapy or psychotherapy and do not include those who take medications irregularly, or improperly, or those who do not have the funds or the emotional strength, the time or the willingness to seek psychotherapy.
Further research is warranted in the area of murder/suicide prevention. Women are diagnosed more often with depression disorder (Bosker et al, 2004).
Technology is an underutilized resource that requires further study. On-line resources are many, all highlighting the need for prevention, identification and cure. Ontario Mood Association (2006), CTV Documentary Fighting the Dragon , and biographies all aid the patient and her family in understanding this disorder.
I firmly believe that we learn from one another's stories...
|Amanda||Autism biographical video|
|Blanco, J.(2003). Please Stop laughing at Me.USA: Turtleback books.||A young woman's journey through bullying.|
|Grandin, T. (1995). Thinking in pictures: My life with autism. New York: Doubleday. Expanded edition published by Vintage, 2006.|
|Jason McElwain||News coverage | Unlikely Hero|
|Mukhopadhyay, T.R. (2003). The Mind Tree. Arcade Publishing.||Autism- an autobiography|
|Sarsfield, M. (2004). No Crystal Stair . Toronto: Canadian Scholar's Press/Women's Press.||Growing up Black in Montreal|
|Simon, L. Detour: My bipolar road trip in 4D|
|The Human Camera|
|Todd, P. (2004). A Quiet Courage: Inspiring Stories from All of Us. Thomas Allen.||Paula Todd interviewed incredible people with incredible survival stories.|
|Ye, Ting-Xing (2003). Throwaway Daughter. Toronto, Ontario, Seal Books: Random House of Canada.||An abandonded Chinese Orphan - raised in the era of the one-child policy.|
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