Depression: The Costly Health Problem in North America

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In terms of productivity and functioning on social, economic and personal scales, depression is the most common and costly health problem in North America (Beutler et. all, 212). No one escapes the ups and downs of life. People suffer disappointments, inconveniences and losses that may upset them all the time. Some get depressed and some don’t. In the case of a grievous loss it is natural to be depressed, but this fades with time and doesn’t impair daily functioning for very long. “The models synthesized in clinical depression produce more extreme negative evaluations of self and more utterly hopeless pessimistic expectations of the future than the models synthesized in normal depressed moods” (Teasedale, 156).

With cases of clinical depression negative feelings can snowball until they are too overwhelming for the person to function. “Signs of clinical depression can include sleep and appetite disturbances, fatigue, an inability to concentrate, memory problems, a decreased sex drive, excessive feelings of guilt, helplessness , and hopelessness, and sometimes thoughts of suicide” (Stevic-Rust & Maximin, 5).

The nature of clinical depression is far more elusive, however, than a list of symptoms can indicate. Depression is comorbid with a host of conditions that may confuse the issue. Also, there are very few symptoms or causes that can be found in every case, few treatments that can work in every case, and the course of depression is never entirely predictable. “Depression is more aptly described as the common cold of emotional disorders or as the fever that indicates the presence of emotional and psychological distress” (Beutler, 254). The many facets of depression and theories which explain depression overlap and are often vague. Only by combining these observations and theories can a clearer picture of the nature of depression emerge.

Depression co-occurs with a host of medical and psychological conditions. Up to two-thirds of people with a lifetime history of major depression have been found to have had a history of other disorders as well (den Boer, 81). Depression is comorbid in sixty percent of general psychiatric patients and over forty percent of people with anxiety disorders (Beutler, 227) Anxiety is comorbid condition with depression that is so prevalent that often times there is trouble separating the depression and the anxiety disorder. There are widely used depression scales in which anxiety symptoms weigh heavily in the final assessment (Montgomery, den Boer, 100).

The psychodynamic model proposes that the primary cause of depression is a “sense of loss”. According to Freud (1917) some extreme of gratification at the oral stage leads a person to be too dependent on others for self esteem and when the object of dependency is lost anger results and is turned inward due to lack of a adequate target (Stevic-Rust, Maximin, 7).

Psychoanalysis in the traditional sense of rehashing traumatic childhood experiences has not proven to be as helpful as other more future-oriented techniques according to research data (Yapko, 56). Although this exploration is helpful in finding problems and seeing how they evolved, excessive ruminating on the past fails to change it and recycles negative thoughts. Finding the source of a problem doesn’t necessarily fix it and the risks of reopening wounds is dangerous with today’s “fast-fix” insurance perogatives.

The biological model of depression assumes that depression is perpetuated or even initiated by chemical imbalances that develop in the brain. Early studies showed a lack of noradrenaline and serotonin led to depression. This led to the theory that “reduced availability of monoamine neurotransmitters could play a role in the pathogenesis of depression” (Montgomery, den Boer, 100).

The role of biology, however, is unclear. “Our genetics and biochemistry play a considerable role in all experiences; even when we consider how much our families or culture influence us, we can say that we are biologically predisposed to be sensitive to our environment” (Yapko, 13). Since medications aimed at altering brain chemistry obviously work, the problem boils down to the question of what comes first. Can someone be born depressed? Is there some inherent weakness that may break with a stressor as in a diathesis-stress model?

Or is the biological imbalance a product of the depression? The question of nature versus nurture has long been an issue with a host of psychological problems, but in the case of depression, the verdict is out. “While there are many correlates of depression at the level of biological processes, few of these processes can be said to be established as causal, and even fewer can be identified as pathological rather than simply variations of normal functioning” (Beutler, 251).

Sociological factors can influence or facilitate the risk for depression as well. Culture defines roles, expectations, philosophies, and any number of other. The different expectations of different individuals can influence the nature and effect of depression. “For men, the most common triggers are job failures and a loss of status. For women, the most common trigger is the cut-off or disruption of an intimate relationship” (Yapko, 19). The roles occupied and maintained within the greater network of society affect senses of stability and acceptance. For instance people who are married have the lowest risk of depression, whereas people who have been recently divorced have the highest risk. Previous extended unemployment and living in urban areas also add to the risk of depression (den Boer, 3).

People who look to others for their sense of self worth and approval are also more prone to be depressed because they are placing their self esteem outside their area of control. This social dependency and lack of self-definition puts them in a position where they can be easily manipulated by anyone who recognizes this (Beutler, 238). These people can end up too eager to please or too afraid of everyone else to function in a healthy way. This excessive need for approval puts everyone else up on a pedestal based on some kind of perceived superiority. If it is recognized it may be enforced by anyone who likes to be on a pedestal.

The fact that the depression rate for women is at least twice that of men highlights the different cultural pressures and variables that can come into play. These rates haven’t been linked to a tendency for women to seek treatment or report symptoms more easily than men (den Boer, 3) so the question is why women are more prone to depression than men.

…some hypotheses suggest that differences in male and female social roles and expected behaviors make men and women differentially susceptible to depression and alcoholism. This hypothesis suggests that women’s proclivity toward passivity and emotionality may make them at higher risk for depression than men. Conversely, this view proposes that the active stance of men, along with their intolerance for emotional arousal, accounts for their relative susceptibility to alcohol abuse as a means of insulating themselves against feelings (Beutler, 233).

Women are also more likely to be subject to controlling and overprotective parental care, which can effect self esteem and contribute to depression. Societal, familial and other expectations can lead women (and men) to have unrealistic expectation for themselves and can also put them in the position of trying to live up to standards that aren’t necessarily their own.

The cognitive model for depression highlights how distortions in thinking can start and perpetuate depression. Beck’s model shows how pessimistic negative thinking is an important factor in the perpetuation of depression (Teasedale, 3). This is linked to the fact that it is easier to recall memories when one is in the state in which they were experienced. For instance if something happens in an intoxicated state it is more likely to be remembered in the intoxicated state in which it was experienced. Since happy events usually are usually accompanied by a good mood, and sad or bad events tend to elicit a bad mood these events are associated with the mood and are recalled more readily in that mood (Teasedale, 20). So a negative mood can bring about all sorts of negative memories which then serve to aggravate the mood, bringing on more negative thoughts and so on in a vicious cycle.

Depressed people’s thinking inherently shows some errors which can be corrected, hopefully breaking learned cycles of negative thinking. Since negative cognitions can lead to negative interpretations and even bring about negative events it is important to attack these distortions. Beck (1976) identified the thought processes that lead to such distortions and develop depression-causing schema as “selective inattention, arbitrary inference, magnification and minimization, and personalization” (Stevic-Rust, Maximin, 8).

Arbitrary inference is the tendency to come to a conclusion without considering all of the variables. These conclusions can often be extreme and with very little support.

Selective inattention is the tendency to disregard information that contradicts whatever conclusions the person has already come to. If someone has a negative self view they are likely to disregard compliments or advances.

Magnification and minimization is the tendency to trivialize positive achievements and exaggerate negative ones.

Personalization is the ability to take ambiguous occurrences as personal attacks or to see oneself as the center of hostility.

Ambiguous data is being collected all the time and needs to be interpreted. This is the basis of the glass being half-empty or half-full experiment. The truth is that it is both but a negative interpretation makes it half empty. The tendency to see and interpret things negatively logically leads to negative feelings and thoughts which serve to perpetuate the cycle of depression. The attributions of ambiguous data can affect a person’s entire outlook on life. There are many conflicting ways to interpret data.

It is interesting to note that according to Alloy (1995) depressed people may actually have more accurate perceptions in some instances in a phenomena called “depressive realism.” Although it is generally agreed that depressed people distort perceptions in a negative direction, it is also true that “normal” people may distort their perception in the opposite way. So in some cases depressed people can see problems for the way they really are instead of easily dismissing them.

It has also been demonstrated that depressed populations are more accurate in determining their levels of personal control, even when control isn’t possible (Beutler, 236). Depressed people are less likely to exaggerate their sense of control, particularly in the positive direction. It has been noted that depressed people have more accurate perceptions of social functioning as well. “Normal” people tend to exaggerate their social performance in relation to the way they perceive the social performance of others around them. Self-ratings by depressed people tend to be closer to the judgments of others around them. This raises the possibility that depressed people are living down to their expectations from themselves based on their self view. This incompetence is noticed by others and may even be acknowledged, perpetuating the condition (Beutler, 242).

“Individuals who have an active, depressed mood tend to make internal, stable, and global attributions of negative events. They tend to see themselves as the cause and objects of blame for such events, while those who make external, situational, and specific judgments are not as depressed as their counterparts” (Beutler, 235).

Internal and external attributions indicate whether the focus is on the self or outside circumstances. If events are blamed on the self then negative feelings towards the self are bound to occur. Blaming the circumstance or environment is much more comfortable even if it’s not necessarily true. If a person stumbles they can choose to blame their inherent clumsiness or the bump on the ground.

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