If you have been to informational websites on depression, then you have a sense of what psychologists consider to be depressive disorders. The typical symptoms are well known, and discussed all the time. Depression actually falls within the general category of “Mood Disorders.” Anyone who has suffered with a bout of moderate Major Depression does not have to be convinced of its impact on work and family life. Many have no doubt run across the term “Bipolar Disorder” and its older antiquated name “Manic-depression.” I consider this diagnosis at greater length in another category on the blog titled “Bipolar.”
The major difference between Major Depression and Bipolar Disorder is a cycle of mania or hypomania. This is not a trivial distinction, whatsoever. Even its milder variant, hypomania, is alarming to others over prolonged periods, and negatively affects occupational and social functioning. Mania is alarming to others over rather brief periods. It is the polar opposite of Major Depression. Often those afflicted are not aware of their expansive mood, or consider it to be a blessing. Depressive people are aware of their symptoms, and sometimes dwell on them excessively. Chronically irritated depressives are often not aware they are depressed, but they are aware of their anger. Consider asking a confidant about your symptoms, since they may provide a fresh prospective. We only know ourselves through the eyes of others.
Bipolar Disorders are less common than Major Depression. Bipolar Disorders are often more debilitating, and with less effective long-term treatment. Severe Major Depression is a nightmare, but add the disorganized frenzy of mania, and it sums to a complete breakdown in functioning. People who suffer with a severe Major Depression have a willingness to commit suicide, and may even experience psychotic symptoms. The type of delusions experienced by people with Major Depression and Bipolar Disorder are quite different, though either disorder may become self-destructive.
Most people using this site are more likely to have a mild form of Major Depression than a Bipolar Disorder. The Bipolar subcategory on this blog is more useful to significant others, than for those who suffer themselves. This is not true for the hypomanic person, as they tend to maintain greater self-awareness than someone with mania. It’s that the hypomanic tends to feel quite elated and energetic, such that a boring old computer blog is not their idea of entertainment. Perhaps those suffering with acute mania are too frantic to web surf, and those with hypomania lack the awareness to consider their condition a problem.
Bipolar Disorder is often misdiagnosed. Hypomania is mistaken for mania, and normal mood swings are taken for hypomania. It is a very serious illness that has almost been reduced to a fad. Twenty years ago, Borderline Personality Disorder was constantly diagnosed and questioned. It is doubtful that Bipolar Disorder will be the last diagnostic fad in the fields of psychology and psychiatry.
Most people have had at least one bout of Major Depression in their lives. Statistically, it’s almost deviant to avoid a Major Depressive Episode one’s whole life. Whereas Bipolar Disorders are rarely aware of their problematic symptoms while manic, the chronic depressive knows they are depressed, but often under-appreciates the severity of their suffering. The depression becomes a backdrop to their life, to the point good spirits seem strange and disconcerting. Once the depression reaches the Moderate stage, it grabs one’s attention in a different way. Physical symptoms rear their ugly heads. Suddenly, you cannot sleep, or conversely, one can’t seem to rouse the whole day. Your appetite is either nil or not capable of being appeased. Chronic anxious rumination is not able to be suppressed. It is not always easy to link all the cognitive symptoms of a depression together, in order for someone to realize they are depressed. Most outpatients initially seek treatment in the moderate stage of a Major Depression, as the physical symptoms assert themselves. It is likely that the moderate stage of depression inspires many web searches.
Generally, treatment is a combination of psychotherapy and medication. The combined treatment is nearly four times as effective as either treatment used in isolation. I believe this rule is most true for Moderate to Severe Major Depressions. I recommend cognitive-behavioral or psychodynamic therapy for treatment of mild depression. I am less concerned about attribution errors in more severe depressions than a milder depression. For example, many of my patients are worried when antidepressant therapy is decreased or discontinued. Often these patients had taken an antidepressant for years without positive results, or were placed on too low a dose of the antidepressant to be clinically effective. Depressive patients often fail to give themselves credit for their hard work in psychotherapy. This is an attribution error, and we all are prone to this sort of error.
Depression-Mild vs. Moderate Severity
In my last post on depression, I stressed the key points differentiating a bipolar disorder from a depression. In this post, I will focus on the differences between mild and moderate symptom profiles, as well as normal mood swings and a Major Depression.
Moderate to severe Major Depressions are easy to differentiate from normal mood swings. The significant difference is titled “vegetative symptoms.” This may call to mind comatose people or someone drooling in a corner; however, the meaning is different. Vegetative symptoms of a depression are the physical symptoms that emerge when one declines from a mild to moderate level of depression. This is the stage where people seek treatment, or are pressured by others to do so. Please keep in mind that the diagnostic rules of Major Depression only differentiate mild from moderate levels of severity based on functional impairment. My contention is that this functional impairment is a direct consequence of the physical symptoms of depression. Often the physical symptoms are so unexpected and alarming that many people believe it is another disorder entirely.
The vegetative symptoms of depression occur in polar extremes; sleep is minimal or too much, appetite is reduced or hunger excessive, energy is decreased or a constant agitated fatigue sets in. It is difficult for people to believe that a psychological problem could cause such physical disruption. Often those who complain of chronic fatigue or general malaise are clinically depressed. Most people expect a depressed person to be very sad and tearful, but a moderate Major Depressive may not have a subjective (personal) sense of sadness, nor may they be tearful. Chronic irritation and general fatigue are often presenting complaints of the chronically depressed. Men are more apt to experience irritation/anger as the prominent feature of depression than women. In the mild phase of depression, a person may be aware of a lowered frustration tolerance, but it is able to be controlled. The moderate stage may reveal rage reactions or simple frustrations that quickly spin out of their control.
Sleep disruption is almost always an important factor in moderate Major Depressions. Few people perceive increased sleep as a problem, yet the increased sleep engendered with a depression doesn’t increase sleep comfortably or effectively. The increased sleep tends to be debilitating. Please note that sleep may be reduced in a Major Depression, but I am focusing on the increased pole, at the moment. Missing work, missed children appointments and missing one’s own appointments are more common than not. Getting out of bed and into the washroom may feel to the afflicted like an epic journey. For example, the daughter of a close friend became moderately depressed. Her nine year old daughter came home each day from school to find her mother in bed. She no longer makes her daughter meals or takes her to school. Increasingly, the daughter takes care of her mother. This dynamic is often observed in families with substance abuse; the course of the treatment is different, but the danger to the family is similar.
As most of us wish for more sleep, we also desire less appetite for food. Supposedly, in excess of a trillion dollars is spent on global weight loss strategies annually. Weight loss secondary to depression is effective, though drastic, unpleasant and unhealthy. The loss of appetite from depression is often gradual, such that it’s cause is obscured over time. Often the sight and especially odors of food will make one feel nauseous. A useful clinical rule is that a ten percent drop in total body weight in one month spells medical trouble. As with sleep, please note that that appetite may also be increased by a Major Depression, but I am focusing on the decreased pole at the moment. Women are more apt than men to be pleased with the weight loss-initially. Others typically remark about the unhealthy appearance of this type of weight loss, decreasing the expected pleasure of hearing peers rave about the missing pounds. This depressive weight loss also entails lower strength and energy, as well as lowered attentional resources. There is little comfort or complements to be gained from depressive weight loss. As with reduced sleep, medications to treat the symptoms tend to prolong or exacerbate the problems. The only known way to combat the sleep and appetite disruption from depression is to treat the underlying depression.
Am I depressed? What an obnoxious question to ask yourself! My earlier posts jumped immediately into specifics and details, such that preliminary comments were lacking. This is an attempt to cover some of the basics-a sort of primer.
Well, are you depressed? It is unlikely that you are searching the web for answers unless there is some suspicion of being depressed; that you are experiencing symptoms not explained by bodily ailments. The task is very challenging, since without professional help, you are attempting to arrive at a diagnosis by ruling out all possible conditions that could account for the unpleasant symptoms. I’ll let my readers in on a little pearl; this is much the same process doctors perform every day in their offices. It is hoped that greater education and experience will make their diagnosis more accurate than yours, but of course, there is no guarantee of this outcome.
So, given these hurdles, where do we start? I suggest writing down the distressing symptoms down on paper. What is more, write down any changes in your functioning, even if it is not distressing or unpleasant. Why? Many symptoms of depression are not unpleasant; for example weight loss or increased sleep in someone prone to insomnia. Most doctors will add up your symptoms in their cranium until a light pops on. The light may be one diagnosis or a group of diagnoses within a category, and further questions or tests will hopefully narrow the disorder to a single name. The trouble with this system is the unavoidable bias of humans, and the narrow focus of the human mind. This results in two major forms of diagnostic corruption; first, the practitioner diagnoses most patients with the disorder that they combat themselves, or second, the limited experience of each clinician narrows their focus to disorders that are not helpful to the patient. A prominent clinician in my area diagnosed nearly every patient with Attention Deficit Disorder. Many staff and patients joked about the doctor’s own attention deficit. While this is less common than the second type of error, do not depend on state or federal organizations from weeding out these clinicians. In fact, they may be quite popular and authoritative.
To help combat errors of bias and limited experience, I strongly recommend using a close friend or family member to discuss the validity of your symptoms. We only know ourselves through the eyes of others. If possible, I also recommend bringing in the trusted person into the initial session with the doctor as an informant. Even if the doctor route is not for you, than I still recommend using a trusted informant to discuss your symptoms prior to making a web search. It is a joke amongst psychology students how we perceive ourselves in every disorder while training. It is natural to say “that’s me” a thousand times while performing a mental health search on the web. For this reason, it is important not to make the web search in isolation.
Physical Symptoms of Depression
A prior post on moderate versus mild symptoms of depression focused on increased sleep and decreased appetite as common vegetative symptoms of depression. I had drawn a distinction between mild and moderate depression as the difference between the severity of physical symptoms, whereas the diagnostic manuals are less specific regarding cognitive and physical symptoms. They tend to focus on the number and severity of both cognitive and vegetative symptoms. I am focusing on what is most apparent to the patient; what actually impels someone to seek professional help. Most depressed people are poorly aware of their cognitive symptoms; especially if they have been manifest for a long time. Physical symptoms are more real and alarming to most patients, than the cognitive symptoms. This does not hold true for severe depressions, as the cognitive symptoms typically outweigh the physical symptoms. Psychotic thoughts and chronic suicidal ideation are two extremely obnoxious cognitive symptoms of depression. I again differ with the diagnostic manuals in that they conceptualize suicidal thoughts as even occurring in mild depression, which I find to not be the case. Severe depressions may manifest psychotic thoughts, and that is in agreement with my experience. The delusional thoughts of the depressed patient are experienced as strange and unwanted, which is a good thing. Truly psychotic individuals have no insight into their malady, whereas the psychotically depressed patient retains their self-awareness. My conjecture is that the primary difference between a mild and moderate depression are the physical symptoms, and between a moderate and severe depression are the cognitive symptoms.
According to the diagnostic manuals, sleep and appetite problems may be present in mild forms of major depression. I find that cognitive symptoms prevail in the milder forms of depression; for example, hopelessness, decreased motivation, sadness, irritability, helplessness, etcetera. The vegetative signs may be present in a mild depression, but are less a focus of the patient’s attention than the cognitive symptoms. The physical symptoms are increasingly noticeable and worrisome in the moderate stage of depression. Typically people are unpleasantly surprised at the level of physical disruption from a moderate level of major depression. A prime example is decreased sleep. This is most noticeable when the patient has a history of good sleep. This may sound obvious, but so many people have insomnia for so many reasons, that disrupted sleep is not unusual to them. Often the person has to experience the reduced sleep for some time before they can differentiate it from common factors that disrupt sleep in their daily lives. Similarly, a person with weight reduction issues may not notice an increased appetite until there is an unusual gain of weight.
If a patient experiences reduced sleep as a consequence of depression, it tends to produce another set of problems. The patient will have difficulty concentrating and sustaining attention throughout their day. They may have brief uncontrolled episodes of unconsciousness, making them dangerous driving an automobile. This nodding off to sleep intermittently is generally not appreciated by their employer, which may increase anxiety about one’s work. Increased sleep secondary to depression presents the greatest risk in terms of missed appointments, whereas decreased sleep appears to this clinician as an even greater functional impairment.
In terms of alterations to one’s appetite, I had focused on a decreased appetite, and the health problems that could ensue. Increased appetite and weight present health problems known to everyone in this day and age. Unfortunately, the average person has learned this message a little too well. Most of the diabetes and atherosclerosis from increased weight is in the morbid range of obesity. A recent very large and well-controlled study investigated survivability amidst groups of people admitted to the hospital for any reason. The investigators found that a patient who is mildly to moderately overweight tended to survive their hospital stay significantly more than underweight and morbidly obese people. The take home message is that mild to moderate weight gain is not likely to pose a medical risk.
It may come as a surprise to many people that in my last twenty years of consultation, nearly all the consults I received regarding weight are for a rapid loss-not a rapid gain. In terms of medical necessity, a rapid weight loss from depression is much more likely in need of treatment than a rapid gain of weight. The greatest problem with rapid weight gain is the functional impairment regarding ambulation and respiration. Both women and men feel worse about themselves after gaining weight, which may deepen the depression. Not being able to play with your children or developing a nocturnal respiratory disorder may further harm and distort a person’s self-image. While unpleasant and embarrassing, increased weight gain from depression rarely presents with the medical necessity of rapid weight loss.
Grief Versus a Mood Disorder
Grief is not considered a mental disorder. It is not even listed by its own name, but goes under the title of “bereavement” in the DSM-IV. Most English speakers will typically use the term of “grief” to describe their emotional reaction after the death or separation from a significant other. The mental and physical symptoms are not readily distinguishable from a Major Depression or an Adjustment Disorder. About 30% of grief reactions meet the criteria of a Major Depression, and about 10% have psychotic symptoms.
Professionals do not regard grief as abnormal if the worst of the suffering is over by 6 months; a year at the longest. Death from suicide or a medical illness is increased significantly during the grief reaction. The immune system is depressed, cortisol levels increase, and there is an increased risk of heart disease and cancerous malignancy during the course of a grief reaction.
Most mental health clinicians will not diagnose grief or bereavement before six months from the time of the loss, though the DSM IV gives 2 months as the guideline. It is normal to have thoughts about actions one might have taken to save their life or keep the person as an intimate attachment. Grieving individuals often feel as if they should have died, instead of their significant other. They typically feel worthless, and experience a profound slowing of thoughts and actions. There is often impairment in social and occupational functioning for several months. It is even common to hear the voice of, or see a fleeting image of, the lost significant other.
It is not the intensity of suffering, but the duration and quality of the suffering that differentiates depression from grief. Visual and auditory hallucinations are common in grieving, but considered abnormal if they persist longer than 6 months. Additionally, the hallucinations of a grieving person are always associated with the missing object; never with someone physically present or personally unknown to the bereaved. For example, if a person experiences hallucinations of their dead father, after the death of their mother, and a voice tells them to kill their brother, this is less grief than a psychotic disorder. Expressions of worthlessness and regret are directly connected to the missing object; otherwise the grief is likely part of a chronic mental illness. Thoughts of death are focused on the missing object. Desiring to die in the place of the deceased, or feeling that life is not worth living without their significant other, is expected and considered normal. Harboring a plan to commit suicide unrelated to the missing object is severe Major Depression.
I hope this article clears up some of the confusion between normal grief or bereavement at the loss of a significant other, and the more unrelenting chronic forms of mental illness. Many people are surprised to learn the level of suffering mental health professionals consider normal in the bereaved individual. They are also surprised that auditory and visual hallucinations of the lost object are common and considered to be within normal limits. As professionals do not recommend treatment for normal bereavement, family and friends of the grief stricken play an invaluable role. Mental health professionals may be consulted if the condition fails to lessen, or even becomes increasingly severe. Most importantly, do not criticize their emotional reactions to the loss. It is best to be a kind and patient listener, rather than an ersatz psychologist. Encourage the mourner to talk at their own pace and rate. Encourage the bereaved to participate in life without being pushy or critical. Also pay special attention to important dates in the relationship between the bereaved and the lost object. Mourners may have worked through most of their grief, but find themselves falling to pieces during times when they would have been together; e.g., the Christmas holidays, birthdays, etc.
Anhedonia and Depression
Some words are not replaceable. There is no one word that can be used as a substitute. One such word is anhedonia. It is rarely used in casual conversation. It is even rarely used by psychologists. As the word was typed, the online dictionary underlined the word in red, indicating that it is not in their database.
The meaning is related to its Greek roots indicating a lack of happiness, yet this could be confused as sadness or a numb feeling. Used in a clinical context, the word means a near inability to derive pleasure from activities once found enjoyable. For example, a person who avidly collects stamps finds their books going unfilled, and a movie buff can’t recollect the last time they went to the cinema. If the person went on to other activities they found rewarding, then the dropping of old interests would not be considered anhedonic. The term is meant to describe a loss of enjoyment that has not found another outlet for expression. This symptom is highly indicative of a depressive disorder, and may be the least understood of the many depressive complaints.
Patients usually associate sadness with depression, and to a lesser extent, sleep and appetite disturbances. It is rare that depressive people have insight into how the disorder affects their daily activities. Typically close others observe the alteration of behavior, and the patient often voices non-depressive rationalizations for the change. The subjective experience of sadness is generally more figural than a change in behavior. Said another way, people are generally more aware of changes in feeling than behavior. This becomes important when someone suffers with a depressive disorder, and they lack a subjective sense of sadness. They may feel angry or numb, but the lack of subjective sadness prevents the person from identifying the problem as Major Depression.
It is not uncommon for a person to be labeled by their family and physician as depressed, and yet have no insight into what others see as obvious. It is common for the person to have an “ah-ha” moment when a microscope is placed on their behavior. For example, a middle-aged man complained that his family and doctors continually labeling him as depressed, yet he didn’t feel particularly sad-let alone suicidal. We discussed his daily activities and how they may have changed over the past year. Subsequently, the man identified a significant loss of interest in professional sports and cooking. He became aware of his loss of interest in activities that had given him the greatest enjoyment. Within six months of accepting treatment, the man was again enjoying sports and cooking. The symptom of anhedonia often serves as an excellent marker of clinical progress.
Anhedonia is a very important symptom of depression because it has little overlap with other psychological disorders. The depressive phase of Bipolar Disorder and Schizophrenia are two areas of overlap. Since the anhedonia only occurs during the depressive phase of Bipolar Disorder, it is still valuable in ruling out other diagnoses. Anhedonia is not a prominent symptom of schizophrenia, and could easily be thought of as a reaction to the auditory and visual hallucinations. Not so much a direct reaction as a depressive reaction to the effect of the delusions and hallucinations on social relationships. It is likely that anhedonia has a much greater overlap with medical conditions, since many physical illnesses can impair a person to the point it is difficult or impossible to engage in “normal” activities.
Anhedonia is not just a nifty word to impress others at a cocktail party. It is a word that often correctly classifies people as depressed who are suffering without insight. It is a symptom that has little overlap with other psychological disorders, such that it is a significant help in making a correct diagnosis. A prospective patient needs to rule out medical conditions that lead to chronic fatigue and low motivation. If this person is deemed physically healthy, yet continues to suffer with a global loss of interest, a trip to the psychologist will help rule out a Mood Disorder.
The Role of Self-esteem
What is self-esteem…really? One does not have to go far to hear that so-and-so would be “better” if only they had more self-esteem. It could also be termed self-regard, confidence or even narcissism. Perhaps a good definition is the realistic but positive appraisal of one’s abilities and deficits. This is rarely what people mean when they use the term. It appears less a realistic self-appraisal than a global sense of satisfaction with oneself. If we only know ourselves through the eyes of others, how is realistic self-appraisal possible? Most self-appraisals are not realistic for that reason alone. If it is skewed toward under-appreciating skills readily perceived by others, then we tend to label these people as modest or depressed. People who espouse self-perceptions that are more grandiose than what others perceive are labeled as arrogant or narcissistic. To be so self-satisfied may not be possible, or even desirable.
Self-esteem is often taken to be a global phenomenon. Once a person catches the self-esteem bug, contentment will blanket all areas of their life. This is rarely the case. More often than not, those who feel very competent in one area view themselves as incompetent in others. An extreme example is the business magnate who is master of all they survey in the daytime, and feels the incompetent fool at night. Most confident people readily admit to areas of their life where they feel a bit shaky. It is nearly a cliche to portray those who boast as actually masking their insecurities. With so many compartments that comprise the modern life, the energy needed to be satisfied in them all would be staggering. Most people form a hierarchy of the important tasks in their life, though they may not be consciously aware of doing so. Those tasks that center about work and family take center stage for most, such that a sense of doing one’s best in either will tend to enhance self-esteem. A constant theme in outpatient practice are those who believe they could have risen higher in work and education. Many people place greater emphasis on family activities that give returns they didn’t receive in other areas. They achieve greater self-esteem by discounting one area and accenting another. Patient’s suffering with grandiose delusions are extraordinarily satisfied with their life, but the rest of us have to make bargains to feel good about ourselves.
It is counter-intuitive, but most people who are at the top of their fields are insecure. Looked at another way, one has to stay hungry to remain at the top. Unless a person keeps an eye on the competition and their skill set, they will tend to decline in any field. Experiencing too much self-esteem may breed a smug indolence that is typical of narcissists. When a winner becomes complacent with their accolades, it tends to diminish their subsequent standing. When a sports psychologist assists an athlete, the treatment rarely takes the form of reviewing their victories. It is stressful to constantly perform at a high level, and one of the stresses is the refusal to be satisfied with one’s performance. If one is thinking of a concert pianist, consider the parent who wanted their child to be a lawyer or doctor. The parent worked long and hard on their academic development. One child is an astronautic and the other is a state senator, yet they regard themselves as a failed parent. Being insecure about their child’s future and their ability as a parent increased the overall effort made with the children. Do not be deceived into thinking that self-esteem drives success. Doubts about oneself may be crippling or highly motivating; depending on how the doubts are interpreted.
So contrary to Mae West, too much of a good thing is not always wonderful. Self-esteem should not come at the expense of motivation and accomplishment. It should not come at the expense of realistic self-perception. We all have to live with the fact we will never be Albert Schweitzer. Sniffle.
The Holiday Blues
Thank God! The holidays are over. This is a common harangue at this time of the year. It seems ridiculous that a time of year intended to give thanks and count one’s blessings should lead to so much tension. Perhaps the unintended consequence is ridiculous, but the ill effects are not. There are many reasons why people become depressed at this time of year, and here are a few. First, the way the Christmas Holiday has been configured in America, it is maximized towards the desires of young children, as their gifts comprise the greatest slice of the economic picture. This echoes the direction of motion pictures to offer material enjoyed by the adolescent and young adult ticket purchasers. This is not an evil plan, to my knowledge, but the typical manifestation of a market to make the most of its opportunities. This does not mean that it will be welcomed by all members of our society, as is clearly the case. Listening to one’s children complain about the paucity or selection of the gifts can infuse the occasion with a sense of meaninglessness. If you are a middle-class American, it is likely you turned in the same performance as a child.
Second, the holidays tend to bring back memories of loved ones that are no longer around. Whether they are deceased or merely estranged is less important than the way we are affected by the distance. There may be an unfulfilled need for this person, or a desire to make amends and reestablish contact. Either way the affected person may be morose or even mildly depressed at a time when we are all supposed to be happy. The expectation that one should be particularly happy during this time of year makes thoughts of loss and longing especially burdensome.
Third, what of this social obligation to be happy during the holidays? Social demands form the core of culture, and we tend to experience feelings when we accomplish or ignore cultural demands. Even if a person is not particularly sad during the holidays, there is an expectation of being happier than usual. If we do not acquiesce to this social demand, we are apt to feel guilt at the lack of our responsiveness. Another perception is anger at being subtly told how to think and feel, even if the consequences of not conforming are nothing more than disapproving looks. The behavioral literature is bursting with examples of how controlling another person’s behavior tends to increase the pressure to resist. People do not like to be pushed into ways of thinking and feeling; unless they believe it was at their initiative.
Fourth, and perhaps the least discussed, is the holidays bring us into contact with people we may not like. Many friends and patients describe the familial and work obligations that are less than enjoyable. Perhaps due to the social demand of being happy and friendly during the holidays, most people tend not to acknowledge this potentially unpleasant aspect of the season. Even in the closest of family and work relationships, there are people one would rather not see more than once per year-if that! To buck and bridle about visiting the besotted “Uncle Jimmy” runs the risk of being branded a “Scrooge.” See, there is even a special designation for those unfortunates who do not have the appropriate “Christmas spirit.”
What can one do to stem the tide of emotions that flood during the holidays? The first is an automatic response to most mental health issues. Wait. Most of the negative emotions dissipate rapidly after the holiday season. Watching the apparently unappreciative children enjoying their toys, and besotted Uncle Jimmy wearing your gift, tends to ameliorate the initial reaction. January is a “git back to work” month when few expect to be particularly happy. Nature obligingly provides cold cloudy days to accomplish all the accumulated work. It seems a bit natural to be down in January, such that the social expectation to be joyful nearly vanishes! As in my other posts on depression, the typical waiting period is three to six months. If your depressive symptoms do not lessen within this time frame, it is likely that a depressive disorder has caught hold and will require professional treatment. Fortunately for most, the negative aspects of this season fade from view as the more positive aspects take hold in one’s memory.
It is a dark day when our lives lose meaning and purpose. Most people do not realize that their lives are predicated on implicit assumptions. Most people take these axioms of their life for granted. If one lives a relatively trouble free life, these implicit assumptions may never be shaken. It is rare to find someone that can hang labels on their reasons to live; that have insight into the meaning of their existence. We all hope our life will sail along so calmly that one’s assumptions about the nature of water will never be called into question. Unfortunately, calm seas and favorable winds are not the norm, such that we are often unrealistic navigators of our own life.
When people tell me that their life has lost meaning and/or purpose, I typically ask what had been the guiding meaning of their lives. Without exception, people do not have a ready answer. They know when it is gone, but are vague about its essence when present. A common purpose of life is to raise children to be successful adults. Most adults, especially older adults, readily agree that raising children was the central purpose of their lives. Roughly half of my adult patients find their work to be meaningful. It is rare for someone to voice an implicit meaning to their lives without naming one or the other, work and/or children. It is rare for people to name an intimate partner as the primary reason to live, or activities outside of work as giving meaning and purpose to one’s life. Exceptions to this rule often occur in childless couples and people who have talent in the arts, but the key word here is exception.
Is there an overriding meaning to life? Can one climb the mountain and obtain an epiphany of the true transcendent meaning of life? I do not think so. Meaning and purpose are unique to the individual, yet there are similarities between individuals. Meaning is congruent with one’s upbringing and experiences, and so the flavor will be change from person-to-person. For example, the purpose of raising children for many people is to send them to college, for others to marry and have grandchildren, and yet others want someone to shield them from the ravages of aging. While all three world views center about the meaning of children in their lives, the purpose and goals of each is different. If one’s vocation fills them with meaning and purpose, is it because of the assistance they render to others, the money they make, or the competitors they crush? Here again we find one meaning and three divergent forms of purpose.
The first step in discovering one’s new meaning in life, the new purpose of one’s existence, is to analyze the nature of the old meaning. It is natural to assume some aspect of the past was a golden age in one’s life, but thorough examination always reveals troubles that had to be surmounted. Know that there is no one grand overriding meaning, but whatever meanings and purposes are congruent with your particular beliefs and values. By way of example, I became close to an older adult patient while training for my degree(s). He was a very loving husband and father. His family held him in the highest regard. They were understandably shocked by his first Major Depression occurring at over seventy years of age. Even before my awareness of these existential issues, it was evident that he no longer felt useful in life. He was satisfied by his performance as a parent, having met the goals he set for himself as a father. The patient became increasingly aware of the satisfaction he experienced mentoring younger business people. He truly enjoyed mentoring others, and more importantly, it became central to his self-image and purpose in life. After discharge, the patient became involved in consulting to small businesses. Until the time of his death, many years later, the patient was not only free of depression, but contented with his retirement as well.
Many people ask, sheepishly, how psychotherapy really works. The term “therapy” is mentioned constantly in the media as a short form of the word “psychotherapy.” It’s natural that people are curious about something that is seemingly ubiquitous, yet apparently defies easy explanation. There is nothing magical or new about psychotherapy. Like most medications, however, there are aspects of its intrinsic functioning that remain a mystery. The nebulous and fleeting words strewn about a psychotherapy session appear, mysteriously, to be less important than the conditions demanded by the therapeutic frame. The “frame” of psychotherapy refers to all aspects of the session divorced from the actual words used within the session: for example, cost, time, place, office policies, etcetera.
Whatever the psycho-therapeutic school of thought, there are set features that are standard across most styles and techniques. The most important element of effective psychotherapy is the promise of confidentiality. Without a solid confidential therapeutic base, psychotherapy is nothing more than a Socratic conversation for hire. One’s life may be blessed by many intimate trusted contacts, yet one cannot divulge literally everything to any one friend. There are always social consequences, and consciously or unconsciously, all of us must monitor and filter the content of our conversations. I do not believe that this encompassing social information management is strictly selfish. As often as not, the filtering of information is used to protect the feelings of others. Having intimate friends is certainly important to one’s mental health, yet even the closest of relationships may be of little use when one’s situation is altered by psychological suffering. For instance, most of my patients are very conscious of becoming a “burden” to others through ventilating their distress. Unless the intimate attachment is based upon this sort of negative ventilation, the voicing of complaints may alter the basis of the friendship. Existing social support may be lost. For this reason alone, close friends are often of little help when psychological distress becomes significant.
Confidentiality is the boiler plate of psychotherapy. Psychotherapy research of the last 50 years is convergent in revealing that the particular therapeutic technique employed is less important than confidentiality in achieving a favorable patient outcome. Part of these findings may be explained by the decreased social risk obtained by ventilating to a professional. Another aspect of these findings may be explained by the very nature of psychotherapy technique. Each school of psychotherapy tends to focus on particular features of the human experience, yet similarities do exist. Broadly, psychotherapy is dedicated to resolving problems that negatively affect one’s life. The relative importance of thoughts versus behaviors differs, yet nearly all seek to identify “maladaptive” thoughts or behaviors that lower a person’s psychosocial functioning. Many schools, such as Rogerian, eschew the whole notion of maladaptive, yet even the most positive and uplifting psychotherapy is seeking to alter one’s thoughts and/or behaviors. It is unlikely that anyone would pursue psychotherapy as a treatment if they perceived their thoughts and behaviors to be wonderful. Many schools of psychotherapy are better at appearing more positive and uplifting than others, but the mission is essentially the same. For example, a new form of psychotherapy is termed “coaching.” This form of psychotherapy/counseling even eschews the whole notion that it is a psychotherapy! As in Rogerian therapy, there is a strong accent on the therapist being positive and proactive. The word “coaching” is synonymous with “instructing.” It appears that some people would forgo the benefits of an intimate attachment to a therapist, in order to avoid being perceived as a “psych case.”
Schools of psychotherapy are targeted towards individuals, couples or families. While the number and relation of the individuals is different in various schools of thought, the mission to discover less than desirable thoughts and behaviors is the same. Many therapists and schools of thought voice a focus on “communication.” I am at a loss to know what else could be a focus of psychotherapy. All psychotherapy assumes communication as essential to the experience, since no therapeutic school pretends to work with comatose or catatonic individuals. Nonverbal behavior communicates a great deal to the therapist and others involved in the session. Verbal and nonverbal communication is the very stuff with which we work, such that the notion of “communication” being a special focus is a bit absurd. The greatest difference between psycho-therapeutic schools of thought are that each tend to emphasize particular features (subsets) of the therapeutic experience; thoughts versus behaviors and individuals versus groups.
If I may draw on the medication analogy again, the use of different forms of psychotherapy is similar to considering side effects in proscribing a particular medication. If we know that two medications will work equally well to cure a condition, which should be employed? The medication with side effects better tolerated by a particular individual would be the obvious choice. For example, the new class of antidepressants called SSRI’s are very good, yet most cause serious reversible symptoms of sexual impairment. If the patient is very sexually active, it might be better to use an older, though less effective, antidepressant without the unwanted sexual impairment. Similarly, group psychotherapy is the most obvious choice to reduce social anxiety, yet initially it may be the worst form of treatment. Exposed to the stimuli they fear the most, a group of people, the patient may experience recurrent trauma as a consequence of this treatment. For this person, it is better to lessen the initial anxiety with individual psychotherapy, and then save the finishing touches for group psychotherapy.
The basics of psychotherapy are centered about confidentiality, a solid frame, and the identification of unwanted thoughts and/or behaviors. The choice of which psychological technique to employ is similar to choosing amongst equally effective medications. The choice of interventions should be based upon the comfort level of the particular patient, in light of their unique situation and lifestyle.
More Issues in Psychotherapy
Perhaps you have read my last post “Psychotherapy 101.” The post “Psychotherapy 101″ is an introduction into fundamental aspects of psychotherapy. It also attempts to dispel common myths regarding psychotherapy. I am satisfied with the post’s information, but a bit unhappy with its tone. Perhaps in my rush to dispel the “fruit and nut” aspects of psychotherapy, I did not give an accurate description of its softer side.
Even though most people seek psychotherapy to solve particular problems, there are those whose mission is to grow as a person. It is easy to categorize these people under the “problem” label, since a desire to grow as a person assumes a certain degree of dissatisfaction with one’s life. Perceived in another way, one may regard these seekers of growth to be satisfied with their lives, yet eager to exceed the boundaries of their current existence. It is less improving a bad thing than making a good thing even better.
Personal growth through psychotherapy is not problem oriented or solution focused. There is no mountain of empirical literature to guide the psychologist’s movements. It is a free style exploration of one’s existence. Psychodynamic therapists have an interesting perspective on this form of exploration. They maintain psychotherapy is the construction of a story that both the patient and therapist agree upon. It is a simple sounding phrase, yet its meaning tends to enlarge as it is turned over in the mind.
The path of the growth oriented patient is less clear than the problem-oriented one. The explicit goals and techniques of traditional psychotherapies render the measurement of progress and success rather easy. The only goal of growth psychotherapy is to exceed one’s current psychological limitations. Neither the psychologist or patient knows how or when the process will end. The psychologist may perceive the patient as complete, but only the patient has the privilege of considering themselves complete. In traditional psychotherapy, the psychologist is largely the owner of this privilege. For example, once the patient stops smoking or their mood is brighter, the psychologist will pronounce success. Psychotherapy is considered complete with the resolution of the problem-oriented goal. In growth therapies, only the patient will truly know when they have reached their goal.
Many growth-oriented therapies eschew goals as an unnecessary stifling of personal exploration. Perhaps this is based upon the assumption that the goals of an incomplete person will be incomplete as well. It may be true that one has to reach a certain level of psychological sophistication to formulate reasonable goals. While this concept rings true for many high functioning people, it is not very applicable to those with more fundamental problems. Working with victims of head injury, the formulation of any goal may be a great victory for the patient. Lacking awareness into their deficits, the psychologist must maintain the privilege of controlling the nature and extent of the treatment. Growth-oriented psychotherapy assumes good cognitive functioning.
Growth-oriented psychotherapy is likely most beneficial to those whose work and home-life are generally satisfactory. Personal growth work is easily derailed by current emergencies and old traumas. Personal growth as a goal is certainly noble and worthwhile. The time and expense are considerable, and the commitment is extraordinary. The shared experience of building an autobiography is very powerful. One cannot help but be altered by the experience. The person emerging from this process has yet to be revealed. It is hoped that greater awareness will bring greater clarity, and the clarity will strength our purpose.
Common ground is an interesting phrase that has been in usage for a long time. A more modern treatment of the phrase is rendered by social psychologists. It refers to the “mutual knowledge, mutual beliefs, and mutual assumptions” that is essential for communication between two people (Clark & Brennan 1991). Perhaps the words “belief” and “assumption” could be compacted to belief alone, since all beliefs are essentially assumptions lacking solid proof. The notion of “belief” is that it is an “assumption” taken as the unvarnished truth, whereas an assumption implies some degree of doubt. The word “knowledge” in contrast to “belief” would mean things that are verifiable; that they can be proven. Common ground could then be rephrased to mean “mutual facts and beliefs that are essential for accurate communication.”
People of different cultures try to communicate all the time, but do they truly understand what the other means? The national outrage at foreign call centers is indicative of this problem. While the person on the other side of the line speaks recognizable English, we are often annoyed that they don’t appear to hear us accurately. Even Americans raised on one coast or the other constantly complain about the attitudes and values of those on the other coast. The other coast just doesn’t get it. The degree to which politeness or directness is utilized can be perceived as either reassuring or offensive. Notions of personal responsibility and a personal work ethic vary throughout this country, and this variability is magnified when examining other countries.
People think that because they speak the same language, their common ground is essentially the same. Many Americans with extensive experience in both France and England report shock as to the degree they feel comfortable with the French, and come to regard the British as a foreign culture. Several years ago, European Journal broadcast a series of video pieces on this very subject, noting how Americans axiomatically believe that England is an extension of American values and culture. While the media emphasizes the “special relationship” between England and America, personal experience tends to find more common ground in France.
The author was reminded of common ground recently at a gathering of old friends and colleagues. Less personal monitoring was necessary because these people have known the author for a long time. Misunderstandings were less likely to occur for the very same reason. Because the group holds similar beliefs, less time was spent in an explanation of the belief, than whether the belief should be held at all! Members of the group may become irritated with one another, but less from a personal misunderstanding, than a disagreement about the fact or belief itself. Facial expressions were accurately interpreted as serious or humorous, which has the tendency to make people more animated. Even the emotional satisfaction of the gathering was magnified by the common ground. Constantly explaining one’s beliefs and core facts is unavoidably draining, and does not appear to have the satisfaction afforded by common ground. Perhaps the curative factor in group therapy for depression is the development of a common ground. It was a wonderful gathering, made even more so by the common ground we still share.
The following is a condensation of a literature review by Dr. Roger Walsh. It appeared recently in the American Psychologist, a journal of the American Psychological Association. Please review the suggested Therapeutic Lifestyle Changes (TLC). These scientifically derived principles for living may benefit those suffering from cognitive and emotional impairments. Fortunately, most of the article is less abstract than practical, and has the additional appeal of common sense. Let us not forget that common sense is anything but common-to paraphrase Mark Twain.
Exercise is one of the most reviled words in the English language. When most people feel like exercising, they lay down until the feeling passes. Another paraphrase of Twain. Joking aside, the influence of exercise on mild to moderate depression has been studied extensively. Its therapeutic benefits compare favorably with medication and psychotherapy. Higher intensity workouts appear to be more effective than lower intensity, but the exact guidelines for each level of intensity is unclear. The effect of exercise on cognition is very good news. For the young, it enhances academic performance. For the elderly, it is an important aide to stroke recovery. Exercise reduces geriatric memory loss, reduces the risk of Alzheimer’s Disease by 45%, and reduces the risk of other dementing conditions as well. Exercise programs of one to three months offer significant cognitive benefits, but those lasting more than six months are more beneficial. The benefits are even more significant if the exercise lasts more than thirty minutes, and combines both aerobic and strength training components.
Diet may be the second most reviled word in the English language. It is often used to denote controlled starvation in popular literature, but it is not the meaning discussed in Dr. Walsh’s article. It simply means one’s choice of food items. Not surprisingly, the chemicals ingested into our body from food have a significant impact on cognitive and emotional health. The best diet is miserably close to what our parents forced us to eat! The diet should be rich in fruits and vegetables, contains some fish, and an eye should be kept on reducing calories.This sort of dietary intake appears to enhance cognitive and academic performance in children, and reduce the severity of mood and psychotic disorders in adults. There is also a reduction in age-related cognitive decline, Alzheimer’s Disease and Parkinson’s Disease.
The influence of supplements on lifestyle has skyrocketed in the last twenty years. The supplements that appear to have a real benefit on cognition and/or mood are Vitamin D, S-adenosyl-methionine, folic acid and fish oil. The benefit appears to be the greatest with fish oil, in relatively high doses of nearly one gram per day, which entails the ingestion of multiple capsules. The fish oil may slow the clotting of blood, such that mixing with other anticoagulants is not suggested. In older adults, the use of fish oil reduces cognitive decline, but is not effective as a treatment for Alzheimer’s Disease. Fish oil may also reduce aggression in children and adults, prevent the onset of psychosis in high risk youth, and have a modest benefit for those suffering with schizophrenia and Huntington’s Disease. Lastly, given its action as an anticoagulant, consider reducing or discontinuing it usage if unusual bruising appears, as well as bleeding from the nose or in the throat. Do not forget that supplements and medications are to enhance and prolong our life. Be quick to reduce or discontinue usage if it is having an overall negative affect. It is easy to focus on the intended benefits, to the exclusion of significant detriments.
The next article will delve further into Dr. Walsh’s literature review. The role of relationships, spirituality, nature and giving to others will be examined in terms of their effect on mental health.
Dr. Walsh’s fourth area of consideration was the role of nature as a mediator of mental health. The psychological cost of indoor living includes disruption of mood, sleep and diurnal rhythms. Cognitive costs of indoor living include impairment of attention, decreased academic performance in the young and a greater cognitive decline in the elderly. Dr. Walsh did report that natural settings reduce stress and depression, but the amount of time spent outdoors to secure this benefit was lacking. Most of the studies he examined appeared to focus on poets and philosophers, such that scientific rigor was minimal. In a normal population, natural settings may enhance cognition, attention, and subjective well-being.
The role of relationships in all social animals is very important. A strong social attachment to a psychologist is more important than the school of therapy that is utilized. Said another way, what the therapist says is less important than their bond with the patient. Good relationships are associated with happiness, resilience, and cognitive capacity. The health risks of social isolation are believed to be comparable to risks of high blood pressure, smoking and obesity. Similar to the section on “Nature,” Dr. Walsh’s analysis of the literature did not include any guidelines for what defines a satisfying relationship, how many are sufficient, and the frequency which one must engage in good relationships to be therapeutic.
This ancient practice of meditation ameliorates a wide array of stress-related psychological and psychosomatic disorders. Mediation has received much more attention from researchers than yoga, and its benefits may overlap with other strategies to induce muscular relaxation. It is clear that meditation is beneficial for normal populations, as well as multiple clinical samples . Dr. Walsh noted that it is less clear how meditation practices compare with each other, or with other therapies; such as relaxation, yoga and self-hypnosis.
Spiritual involvement may be an important mediator of mental and physical health. It appears to be most beneficial when centered on themes of love and forgiveness. Themes of guilt and punishment are less likely to be helpful to one’s mental health. Those who attend religious services at least weekly live about seven years longer than those who do not attend. Those who experience a rich spiritual life have reduced rates of mental disorders; such as anxiety, depression, substance abuse and suicide. The only significant link between spirituality and physical health is a reduced incidence of hypertension. A common criticism of this area of research is that the sample of people who attend church are less likely to smoke, drink and abuse drugs. Since their lifestyle is inherently different, it would need to be compared to spiritual people who indulged in these common vices.
In the concluding section of the literature review, Dr. Walsh discussed the so-called paradox of happiness. The nature of the paradox is that spending time helping others may accentuate one’s personal happiness. A major exception to this category is caretaker burnout. When family members take care of a demented spouse or parent, the sense of internal pressure and obligation may negate the positive affects of contributing to others. There is considerable research to link selfless behavior (altruism) with psychological, physical and social well-being. In some cases, providing social support may actually be more beneficial than receiving the help.
Growing Older, Not Bolder
There was an initial shock in providing psychological services to nursing homes. It was less from the environment than the unexpected nature of the patient’s comments. Bed-ridden patients warned staff to make travel arrangements as soon as possible; do not wait until they are too old and sick. Most believed the whole notion of the “golden years” to be a cruel myth. The very mention of “golden years” often forced an eye roll-even overt anger. Story after story related a lifetime of work and sacrifice, with the view of saving money to effect a pleasant retirement. The climax of so many stories was that a serious medical problem interrupted their plans. Despite time and money, the retiree was not going beyond their front door.
Another unexpected facet of nursing home culture was the perception of children. So many had come to believe that their offspring were downright traitors. The truth is that responsible children are often required to liquidate their parent’s assets to pay for medical care. This rarely sits well with the parents. It is especially bothersome to those with dementia, since they are unable to understand the rationale for the actions of their children. Often such demented patients only retain the emotionally charged aspects of the message, which is typically that their home was sold beneath them. The logical conclusion, based on the few facts they retain, is that the children want to grab their money before they die. This is rarely the case. It is heartbreaking for the children to perform so much work for their parent, only to be regarded as little better than a criminal.
The brooding disappointment of extreme old age is not just relegated to the depressed individuals. The loss of independence rarely sits well with Americans. Many cultures appear to accept this as unavoidable, but Americans do not like the word “unavoidable.” To work and plan for decades, only to be thwarted at the last moment, strikes Americans as horribly unfair. The experience of other cultures is that life is often unfair, and this fact does not improve with age. The American perspective on fairness is less prevalent with the older generations. Two world wars and a depression impacted them in a way that is foreign to baby-boomers and beyond. It is likely that the reaction of subsequent generations to nursing home placement will be increasingly negative. While the WWII generation is less apt to gripe about fairness, they remain extremely adverse to depending on others.
The main deterrent to a bad nursing home placement is a realistic perspective. We all grow old and die-if we are lucky. That sounds cruel to those outside the health care industry, but it is self-evident to those who are involved in the system. Many individuals suffer and die while relatively young. Perhaps the best adjustment to nursing home care is observed for individuals that were sickly in their youth, and never expected to live to a ripe old age. These people were forced to adopt an existentially realistic attitude at a young age. As mentioned, many cultures are happy with basic subsistence. They appreciate the personal service in a nursing home, since such luxuries are foreign to them. For most Americans, there are never enough staff, and they never come quick enough to suite their taste.
A change in perspective would also alleviate rancor between the patient and responsible children. In order to liquidate assets to pay for medical care, children are often forced to seek the paid assistance of consultants. It would simply the process to have disinterested third parties perform this action, as part of the government benefit. Strangely, even demented nursing home patients rarely become agitated over this process if performed by an attorney. While the author has listened to thousands of complaints regarding the motives of the children, even one such complaint directed at an attorney cannot be recalled. This should not be taken as an endorsement of attorneys, rather it speaks to the reduced agitation inherent in having a third party manage the assets. Since most people cannot afford attorneys, it is necessary to make the service part of the Medicare or Medicaid benefit.
Growing older is not a right, but the benefit of a life well-lived. Even though fifty percent of nursing home patients return home, the typical belief is that nursing homes only function as a place to die. Often, the staff and doctors do not know who will improve, such that the patient is held in a state of suspense. Placement within a nursing home may be the final hurdle; a concrete message that one’s life is limited and will soon be over. How well we accept this message says not only a lot about ourselves, but also the culture that has influenced our values and expectations. Still, all in all…it’s probably better to take that world cruise now.
Genetically Modified Depression
Most people know that DNA contains the data that programs all living things. What is less known is how the shape of the DNA affects the ultimate expression of proteins. The mechanisms that regulate if and when proteins are expressed by the DNA template is a very hot topic of research. Not only the packing but the chemical markers attached to the DNA appear to be important in gene expression or inhibition. Vast areas of DNA that had been labelled as “junk” are increasingly found to be important in the regulation of protein production. Only a few percent of a person’s DNA is actually a blueprint for protein production. The remainder is an intricate network of feedback and feed forward mechanisms that start and stop protein production. Tightly packed DNA tends to decrease protein transcription, and relaxed DNA strands increases the chance a gene will be expressed. Two groups of chemical markers have been discovered that regulate the DNA packaging, and hence the ultimate expression of any particular gene. So, one may ask, what has this to do with mental health?
The chemical groups that regulate gene expression are critically important to the understanding of addiction and depression. Within an hour of injecting mice with cocaine, over one hundred genes become activated. If cocaine is used everyday, particular genes are actually inhibited from expressing proteins. Prolonged use may render some genes over-activated for weeks and even months, whereas others become chronically inhibited. The ingestion of this one chemical causes profound genetic alterations in the brain’s reward centers that may persist long after the drug is discontinued. Many genes remain highly sensitized to the effects of cocaine for several weeks after the mouse was last injected. The brain is ready and waiting for the next dose of cocaine. The cocaine causes the epigentic chemicals to loosen the strands of DNA; priming them to be activated.
In depression, the the epigenetic influence on DNA is nearly opposite to that of cocaine abuse. Depression appears to be the consequence of repressed gene activation in the reward centers of the brain. Environments that are abusive will tend to make the DNA strands tightly bound; decreasing gene activation. For example, a mouse that is not able to escape the domination of a more powerful mouse will display decreased activation in twelve hundred genes! Depression appears to inhibit the activation of DNA in the reward centers that allow an animal to feel good. Just as many humans are resistant to depression, about one third of the mice in the bully experiment did not manifest symptoms of depression. The resilient group of mice did not develop the the inhibited gene expression that infected the larger depressed group. This sizable group of genes in the reward center of higher animals is implicated in the treatment effectiveness of tricyclic antidepressants. Some antidepressants may actually boost the brain’s natural mechanism to confer resilience.
Addiction and depression are not the only psychological manifestations of epigenetic modulation. As described by Eric Nestler in Scientific American (2011), epigenetic “modifications can promote behavioral changes that last a lifetime.” Maternal rat behavior is partially or completely modulated by epigenetics, and this has lasting effects on the offspring. The memory area of the mother’s brain is inhibited, and this epigenetic reduction increases the stress response of the mother over their lifetime. Anxious and fearful mothers produce a change in the epigenetic regulation of their pups, and this effect will reverberate down the generations. The behavior of the mother will alter gene expression in their children, and their children’s children.
As with so many discoveries in neuroscience, what works in a mouse may not generalize to a human. It is likely that humans have the same epigenetic marks that influence gene expression, but it may deviate from what is observed in mice and rats. Additionally, the complexity of the human brain often makes it difficult to reduce an observation to a few simple rules of organization. It is nearly impossible to tease out the influence of genetic inheritance from the effects of the environment. The relative influence of environment versus heredity has been hotly debated for decades, if not centuries. If this research proves valid in humans, it renders the nature versus nurture debate practically moot. Increasingly it appears that the environment has a profound and lasting effect on gene expression. The role of gene expression can no longer be considered in isolation, as if it is the last word in the life story of the organism. Perhaps the duality of genes and environment will have the same fate as that of the mind and body. One can only be understood in relation to the other.
A recent review on the prevention of depression was featured in the May issue of the American Psychologist. The study authors (Munoz, Beardslee and Laykin) were decidedly positive in their appraisal of current prevention efforts. As the authors point out, prior to the 1980’s, it was the official position of the mental health gods that depression was not preventable. The last two decades have seen a reversal of this thinking. Psychologists from around the world have researched programs designed to prevent depression in the general population. Most of the prevention studies cited by these and other authors share many commonalities. First, the research subjects are randomly assigned to treatment and no-treatment groups. Second, the treatment group receives a course on the identification and reduction of depressive symptoms. The depression group intervention varies from a traditional lecture format to group therapy with an identified leader. Lastly, the prevention studies compare symptoms of depression at the beginning of the study with symptoms experienced at the end of the study. The authors then write a report summarizing their positive or negative findings.
Though their intent is certainly noble, the depression prevention researchers have encountered problems with methodology. The first problem is with the method to recruit and classify the study subjects. In order to lower the total number of subjects needed to complete the study, psychologists often use “at risk” individuals to populate the study. The term “at risk” has several meanings in the context of psychological research of this nature. A research subject may have experienced a prior depressive episode, there’s a family history of depression, they live in poverty, or the subject endorsed subclinical elevations on depression questionnaires. Subclinical refers to the manifestation of an abnormal number or type of symptom(s), yet they fail to meet the criteria of a known clinical condition. Unfortunately, the use of “at risk” people lessens the statistical power of the study. No longer are the study subjects randomly assigned to groups, but selected because of a particular trait. The psychologist cannot then compare the depression intervention to the general population, rather the comparison may only be drawn to other “at risk” groups.
Such group interventions may also fall prey to an old psychological phenomenon. Many years ago, psychologists who studied factory production noted consistent productivity gains across the length of the study. This phenomenon was titled the “Hawthorne Effect” after the name of the factory where it was initially observed. It was discovered that factory workers performed at a higher level when they were aware of being observed. After the study was terminated, the efficiency of the workers returned to the original lower level. Similarly, depression prevention subjects are aware of being observed and evaluated. Not only is there the Hawthorne Effect, and a normal bias to please the examiner, but mood is often elevated with the perception of special treatment. Sham groups may be utilized to counteract the natural biases and effects of being observed. A sham group is one where any subject may be discussed, with the exception of the issue being evaluated-depression in this particular case. The subjects attending the sham group may then be appropriately compared with groups that do discuss depression. The use of a sham group component will increase the power of the study. It will help differentiate whether a drop in the incidence of depression between groups is due to talking and lecturing about depression, or whether being observed and receiving special treatment accounted for the reduced prevalence of depressive symptoms.
It is certainly the author’s hope that depression is at least partially preventable. Many of the current interventions in use may be valuable, but the present design of these studies limits the power to draw accurate conclusions. Larger study sizes, that are truly randomized, should be combined with sham group interventions. Until there is an increased mindfulness of proper investigatory techniques, the current depression prevention results are not convincing. Stated another way, the correct prevention techniques may already exist, but hard evidence of their effectiveness is lacking. Let us all hope that psychological researchers discover effective methods to prevent depression, as it would not only benefit commerce, but our everyday social experience as well.