Posts tagged: major depression

Preventable Depression?

Business Logo for Psychological and Neuropsychological IssuesA 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.

Anhedonia

Dr. Holzmacher's Business LogoSome 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.

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