THEORIES ABOUT THE CAUSES OF DEPRESSION

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 It is enlightening but perhaps discouraging to realize that sadness and its associated depressive symptoms can have many causes. We will review the major theories.

Loss

 While this is no profound theory, it is more far reaching than you might at first realize. Depression is, of course, the normal, natural reaction when we lose something we value. A friend or loved one dies and we grieve. A loved one leaves us and we hurt, we miss them and want them back. We fail to reach some important goal and we cry. Mc Coy (1982) lists several triggers to teenage depression: death, separation from a parent by divorce or work, loss of friends by moving, loss of love, loss of dependency and childhood by growing up and joining a peer group, loss of confidence when criticized, loss of traditional values that are not replaced by other guides to living, loss of health, loss of goals (especially after working long and hard for some achievement), poor communication with family, family conflicts, and having depressed parents.

 A recent survey at the Medical College of Virginia found that interpersonal losses (death, marital problems, loss of a friend, job loss) remarkably increased the risk of clinical depression in women. But only about 25% of depressed persons have suffered such losses and not everyone who does gets seriously depressed. Martin Seligman and Gloria Steinem suggest the Baby Boomers grew up expecting the world to be a wonderful place but instead are finding it to be cold and unsupportive. As economic conditions worsen, there is no safety net when we fail--no close family, no helpful neighbors, no concerned co-workers, no church, no kind and gentle government. True, life today has its stresses, but is it more stressful than marrying as a teenager, settling on a remote homestead in 1830, running the risk of death in childbirth or in infancy, and raising a family in the wilderness? I think not.

 Yapko (1992) makes the point that your value system and life style (reflecting childhood, friends, and family background) affect your outlook on every event in your life and on everything you do. Your values determine what you see as important and unimportant, as good and bad, as normal and abnormal, and so on. Furthermore, anything you value becomes a potential threat--something you would hate to lose. Examples: If you value being cared for by loved ones (to the extent of being dependent), a scary loss might be graduating from college or getting a divorce. If you value your looks highly, you will lose a lot over the years. If you value financial success but can't achieve it, that is a loss. If you value a close relationship with your children, but they are taken away by divorce, it may be a terrible loss. On the other hand, if you do not value day-by-day some activity (and, thus, don't devote time to it) but psychologically you need it, you have also experienced the loss of something important. Examples: a person, who throws him/herself into either work or child care and avoids the other activity, may only find out years later what he/she has lost.

 What are the points here? (a) If depressed, try to recognize the losses you may be responding to. (b) Realize the intimate connection between your values and your regretted losses. (c) Try to reduce your losses, if possible. And, perhaps, join community efforts to reduce other peoples' losses--and thereby reduce your own losses.

Genetic-physiological-chemical

 Ancient drugs, like reserpine, cause depression; others, like heroin or opium, cause elation. So there is reason to suspect that some naturally occurring "chemical factors" in the brain could influence depression. Also, the environment is a factor, consider "blue Mondays" and wintertime depression (relieved by full-spectrum lights). Likewise, as we will see, genetic factors clearly play a role, at least in the most serious forms of depression. Even proneness to minor stress and mood swings may be partially inherited. And, physical treatment, like electric shock, may reduce depression. My point again is: the causes of depression are complex and only partially understood.

 Note: every once in a while, some amazing finding comes along that shakes your thinking about a mental disorder. (Often the finding is an accidental outcome which doesn't hold up over time, so know about the finding but be cautious.) Very recently (2001) a press release by Stanford University psychiatric team reported that the abortion pill RU-486 had reduced serious psychotic depression symptoms within four days for five women. These women were not pregnant, so this isn't related to having an abortion. The theory is that a hormone, cortisol, is associated with psychotic depression and RU-486 blocks the brain's receptors for cortisol. The drug seems to only help this one disorder. Interesting. More studies are being done. Stay tuned.

 Studies of identical twins, fraternal twins, adoptees, and several generations within a family, suggest that your general level of depression is partly inherited but not your level of happiness (discussed in introduction). Your conscious efforts can influence happiness regardless of the messages from your genes. However, if one identical twin has a serious depression, the other twin has a 65% chance of being depressed. Since 35% of the time one twin did not become depressed, one could ask to what extent did the nondepressed twin overcome his/her genes? We don't know. Maybe the depressed twin is suffering from psychological causes. Again, we don't know but in dizygotic twins the chance of the other twin getting depressed is only 14%. Kendler, et al (1993) estimates that genes account for 41% to 46% of the variance in depression. Clearly, depression runs in families. The genes and the family environment are both involved, but several studies find that it is individual specific-environmental factors that influence depression and not shared family events, such as the death of a parent.

 How physiologically do the genes, environment, and drugs influence depression? Current speculation is that these factors influence the transmission of nerve impulses (involving chemicals called neurotransmitters) in the brain. Too little of certain neurotransmitters (norepinephrine or serotonin) supposedly results in depression, too much in mania or overactivity. Helpless rats shocked repeatedly act depressed and lose their norepinephrine (Ellison, 1977). Rats in a similar situation but able to turn off the shock themselves do not act depressed nor get deficient in norepinephrine (Weiss, et al.,1974).

 Another theory is that the "general adaptation syndrome" is responsible for depression as well as stress (see chapter 5). Remember the third stage in this process, after an alarm reaction and resistance, is exhaustion. Depressed people feel tired, drained of energy, "I just can't get going." Other symptoms--poor sleep, appetite, and sex drive--are regulated by the hypothalamus, so it may be malfunctioning. The real question is: What causes the stress or the neurotransmitter or the hypothalamus changes? We don't yet know.

 If a person's depression involves radical bipolar mood swings (feeling high and then low), delusions, and a high risk of suicide, some form of medical treatment (drugs and hospitalization) in addition to psychotherapy should be given. If the depression does not include any of these factors but does include other physical factors mentioned above (see signs), medication would probably help (Kocsis, 1981). Even when there are no signs of physical illness, i.e. it seems to be psychological, the treatment of choice is psychotherapy with medication as needed. It isn't understood why or how but anti-depressive medication changes cognition, and cognitive therapy, believe it or not, changes body chemistry (Free & Oei, 1989).

 Other physiological conditions are related to sadness and anxiety, for example, postpartum conditions, hypoglycemia, and premenstrual syndrome. Hypoglycemia may have been overemphasized in the 1970's but premenstrual syndrome is a devastating problem for some women. One woman was hospitalized 13 times for suicidal depression before someone noticed that each admission was one or two days before her period (letters, Ms, p. 4, January, l984). More commonly (estimated from 20% to 80%), women experience increased tension, headaches, irritability, and sadness prior to their periods. There are likely to be complex physiological and psychological causes but we know little about premenstrual stress, thus far. Research is badly needed (Eagan, 1983).

 A word of caution: believing in physical causes, such as psychiatrists' favorite expression "chemical imbalance," may interfere with assuming responsibility for changing yourself. Examples: "I'm on medication" or "I get depression from my mother" or "my system is all messed up." Lewinsohn & Arconad (1981) reports that many depressed patients see themselves as physically ill, as victims of some bodily disorder. Thus, they expect the "doctor" or medicine to magically remove their sadness--otherwise, they feel helpless. (Of course, the opposite misunderstanding is equally harmful: when physically caused depression is treated with psychotherapy, prayer, illegal drugs, alcohol, talking to friends, self-help....) Don't neglect the possibility of either physical-chemical or psychological-environmental causes.

The very idea that drugs are the answer (to depression) suggests a moral, psychological, and spiritual vacuum.
Peter Breggin (1994)

Poor social skills = no fun

 One social learning theory (Lewinsohn & Arconan, 1981) proposes that depression is a result of an unrewarding environment and the person's reaction to it. This is like the loss theory (1) except there is a twist: the "depressing" environment may not be painful, it may just not be any fun--it provides no pleasure, no "positive reinforcement." That could be depressing!

 Lewinsohn and his associates have shown that depressives respond slower and less often to others. They don't get others to respond to them; thus, they get fewer social rewards (less fun) than nondepressed people. More importantly, depressed people arouse more anxiety, anger, depression, and rejection in others than "normals" do (Coyne, 1976). How? By too many complaints, requests for support, and premature discussions of personal problems. This may account for staying depressed but it doesn't explain why the social interaction and skills decline.

 Coyne suggests that this sequence of events occurs: (a) some stressful events happen, (b) depression-prone people need more social support and nurturance than others when under stress, (c) but they have fewer social skills for getting the extra support needed, which worsens the depression, and (d) they start relating in ways that drive others away, which maintains the depression. Indeed, 70% seeking therapy aren't getting what they want from their spouse (McLean, 1976). Some questions still remain about this theory: Why do they need more support? Why do they lack these skills? Why can't or don't they figure out how to have more fun?

 Recent research has studied which behaviors of depressed students drive roommates away (Joiner, Alfano, & Metalsky, 1992). Tentative findings are that depression per se doesn't turn people off, but certain behaviors by self-depreciating depressed people do, such as excessively seeking reassurance that the other person cares. This is true especially between males. Obviously, how the depressed male is received also depends on the characteristics of the "friend." For instance, an empathic, tolerant, caring person would not be rejecting, except under the most trying circumstances. Perhaps males are rejected more for seeking support because they are supposed to be self-reliant and "suffer in silence." Perhaps depressed women are rejected for other reasons. In any case, there is clear evidence that a depressed friend is depressing.

 Ferster (1981) says the depressed person is so overwhelmed by their loss and anger that they can't respond effectively to the environment (to others) to get what they want. Rather surprisingly for an operant behaviorist, he implies this insensitivity to how-to-get-what-we-want may come from early feeding experiences where the infant responds more to the internal urge to eat (making demands--which get reinforced) than to interacting and playing with the feeder. Like the fussy, demanding baby, the depressed person becomes fixated on complaints, criticism, demands, and loud cries of distress (all punishing or aversive to any listener). Instead of seeking positive reinforcement, they have learned to only punish and complain; they hurt too much to do otherwise (like the hungry infant). By being so glum and critical (and insensitive) they only drive others (sources of fun) away. By therapy or self-education they must learn other ways of interacting.

 Lewinsohn's approach to therapy is to first pinpoint the punishing events present in the sad person's environment (usually marital problems, work hassles, or criticism) and the pleasant events absent (including friends, love, sex, fun activities, satisfying solitude, and feeling competent). Then by careful, daily rating and plotting of one's behavior and the resulting feelings, the therapist shows the depressed person that the environment (and how they handle it) truly does determine their depression. Treatment consists of teaching the patient how to decrease the frequency and hurtfulness of unpleasant events and increase the frequency and appreciation of pleasant events. This is done by using many techniques, like those in chapters 11, 12, and 13, but mostly behavior change or social and cognitive skills to increase positive reinforcement. The University of Oregon started a class in "Coping with Depression" (Lewinsohn & Arconad, 1981).

 You might notice that this is the same basic notion as most dynamic psychiatrists operate under, namely, that most emotional problems originate in our interpersonal relationships. Surely it would work in the opposite direction too: if I became very sad, impatient, demanding of attention, lethargic, and grouchy, I'd surely develop interpersonal problems. So which comes first, sadness or poor social skills? Have life events been painful or just no fun?

Recent research confirms the importance of positive experiences

 We therapists and writers focus on reducing unpleasant negative emotions--anxiety, fears, depression, anger, dependency and so forth. We do this partly because patients frequently have gotten into a sink hole of obsessive scary, irritating, or sad thoughts and feelings. Also, our therapy methods are oriented toward reducing symptoms. Research, however, has shown that positive thoughts and experiences reduce the negative reactions we have to stress, loss, frustration, and helplessness. Therefore, distress and unhappiness can be reduced by using a variety of pleasant, satisfying or promising coping methods, which are different from traditional therapy methods. Note that how well we cope is related to (a) perceived characteristics of the upsetting situation, such as how changeable the situation is seen to be, (b) personality factors, reflecting such traits as optimism, self-efficacy, toughness, a sense of humor, and neuroticism, and (c) social resources the person has, such family support, a devoted friend or therapist, a fun group, etc.(Folkman & Moskowitz, 2000). To some extent these factors are within our self-control.

 What other coping methods might indirectly ease the pain of fear or depression? One would be cognitive reappraisal or "reframing" or "benefit finding." If there is one little bright spot, a ray of hope, or one good thing, the situation is not so bad. You have to look for the positive, however, so that you will not be overwhelmed by the gloom. In bad situations, such as caring for a sick loved one, the bright spot may be the satisfaction you feel about your steady contribution to their care. Don't dismiss the good. And, at the other end, don't over-estimate or reinforce the bad feelings (see Woundology).

 Another aspect of coping that yields positive feelings is the fact you are trying to improve the situation. Problem-solving efforts focus our attention on the important and changeable aspects of the distressing situation, motivate us to try something, give us satisfaction when we try, and lead to mastery and pride if we have some success.

 A third way to see the positive is to ask yourself "did I do something that made me feel good?" Most people can find some things, but you have to look for them and remind yourself that even in the midst of an awful situation good things are still happening. So, in the footsteps of Lewinsohn 20 years ago, today's cognitive therapists often ask their patients to schedule positive events and to look for positive meaning. The more positive events and experiences we can have, the more we reduce the depression (Dixon & Reid, 2000).


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