Depression is a word we hear a lot in our daily lives. Worldwide, there are 340 million people suffering from depression, ranking fifth in the world and expected to rise to second place in 2020. But many people still lack a comprehensive understanding of it, putting a veil of mystery over it. In fact, it is a very common mood and emotional problem that many people may deal with during their lifetime.
Symptoms and clinical manifestations
Depression is usually characterized by a persistent low mood and a loss of interest. It can also cause physical discomfort such as disturbances in appetite, sleep problems, loss of thinking and energy, and so on. Only people in very severe depression may experience suicidal thoughts and behaviors.
Many people define depression as a specific illness and summarize the course, treatment and prognosis of the illness. The prevailing view is that psychotherapy combined with medication is the most effective treatment for depression. The first treatment of depression requires maintenance treatment with adequate doses of antidepressants for more than six months. After the first episode is cured, there may be a 50% probability of relapse. If there is a relapse, then both the dosage and the duration of maintenance need to be increased. If there are more than two relapses, then lifelong medication is required.
Many people suffering from depressive states who are informed of the above medical opinion are likely to lose confidence first before they are treated. When people hear about lifelong medication, they feel scared that they must have a particularly serious and incurable disease.
Although people in a depressed state will experience the uncomfortable symptoms mentioned above, our view is more optimistic; the vast majority of depression is neurological rather than endogenous, and we do not tend to view it as a form of illness because although some changes occur in the brain of people with depression, these changes are temporary, functional, and reversible. The physiological changes in the brain of a neurologically depressed person are normal physiological phenomena resulting from prolonged exposure to adverse emotions; it is not organic, nor is it brain damage, and it can be completely cured by appropriate means. It is unfortunate that many doctors consider depression to be a disease of the brain. Secondly, if it is seen as a disease, the patient will acquire a strong patient role and it is easy for them to look down on themselves and aggravate their low self-esteem or to shirk their responsibility and put the task of healing entirely on the doctor. This is very detrimental to the patient’s recovery.
Patients can examine whether they are depressed or not by themselves through some self-rating scales, including Beck Depression Inventory (BDI), Depression Self-Rating Inventory (SDS), and Depressive State Inventory (DSI), which have a good reliability.
Etiology
What exactly is depression and how does it develop? There are many theories that explain the causes of depression. We will focus on a few of the most important ones, including cognitive theories, behaviorist theories, existential and humanistic, and biological factors.
I. Perspectives of cognitive theories
Among the cognitive theories of understanding depression, Aaron Beck’s theory has been the most influential and has been supported by numerous empirical studies.Beck argues that each of us possesses a variety of schemata, our internal attitudes and beliefs about the world and life. Through these schemas, we regulate our lives. During childhood or adolescence, depressed people develop negative schemas or beliefs – a tendency to view the world around them negatively – because of certain reasons, such as poor treatment by parents, failure to integrate well into school life, and poor attitudes toward life on the part of guardians themselves. So once they encounter difficulties in life, they are more inclined to see things negatively, and they have more than the usual feelings of hopelessness and low self-esteem. Such a schema also often plunges the ego into an abyss of meaninglessness, and a sense of worthlessness. In this way, depressed people are often troubled by bad emotions and they easily fall into depression.
The behaviorist view
Behaviorists have two main theories to explain depression, one emphasizing external reinforcement and the other emphasizing interpersonal processes.
Many behaviorists see depression as a result of fading, and consider depression to be an incomplete or inadequate activity. The meaning of fading is that once a person is no longer reinforced for a behavior, the probability of people exhibiting that behavior again diminishes or even disappears. For example, a recently retired person may feel that positive stimuli are scarce in the identity of the environment outside the office after the loss of a job. A man who has lost his wife may find that the scenarios in his life that used to make him happy are now gone. A number of studies support Lewinsohn’s view that depressed people might improve their state of mind if they learned to reduce the frequency of unpleasant events and increase the frequency of pleasant events, as normal people do. It is the depressed who lack the ability to obtain reinforcement and interact with others (Acocella, 1996).
The finding that depressed people are more likely than non-depressed people to react negatively to the people they come into contact with forms the basis for interpersonal treatment of depression. According to this view, depressed people have an annoying behavioral style. They always force those whom they feel are no longer adequately caring for them to care for themselves, and often receive not love but rejection from their family and friends. There are many studies that support the interpersonal theory of depression. For example, one study showed that patients who were also depressed were more likely to relapse 9 months after healing if they were often criticized by their spouse than if they received acceptance from their spouse. Now, although it cannot be said that it is this behavioral style that causes depression, the depressed person’s poor interpersonal relationship style is one of the important factors in the persistence of depression.
III. Humanistic and Existentialist Perspectives
Existentialists believe that depression is a sense of non-being that arises from a failure to live fully and authentically. It is a breakdown of the individual’s value system for himself or herself. Existentialists believe that the abundance of life, technological progress, and political democracy do not solve the problem of why and how we live. The depressed person’s lack of meaning in life is a major cause of his or her “non-existence”. Humanistic and existential psychology have many supporters in Europe and the United States, but it is still difficult to make empirical studies on their theories.
Biological factors
Biological studies on depression show that biological factors play an important role in depression, regardless of environmental changes. Current research on the biological aspects of depression focuses on genetics, neurotransmitters and neuroendocrine dysregulation.
1. Genetic factors
Studies have shown that the prevalence of depression in relatives ranges from 1.5 times to 3 times that of the general population. In twin studies, the co-morbidity rate for depression was 40% for identical twins and 11% for heterozygotic twins.Kendler’s study suggests that 40%-45% of the differences between identical and heterozygotic twins should be attributed to genetic factors, with the remainder attributed to individual differences in environment, i.e., different life events experienced during the individual’s life (Alloy, et al, 1996).
In studies of depressed adoptees, it was found that blood relatives of depressed adoptees were significantly more likely to suffer from depression than their adopters (Wender et al, 1986).
2. Disturbed neurotransmitter regulation
Most biochemical theories of depression have focused on neurotransmitters, which act to facilitate the prominent transmission of neural impulses in neurons. Much of the research on these has focused on monoamine neurotransmitters, and the main neurotransmitters associated with the onset of depression are 5hydroxytryptamine, norepinephrine, and dopamine. Early theories suggested that the onset of depression was due to an excess of these monoamine neurotransmitters at the synapses of neurons (Glassman, 1969; Schidkraut, 1965). The mechanism of action of the vast majority of drugs currently on the market for the treatment of depression focuses on mentioning the concentration of these neurotransmitters between neuronal synapses. However, since first-line antidepressants such as ssri increase the concentration of these neurotransmitters as early as 1 hour after administration, their antidepressant effect waits until a week later, and the drugs are rarely sufficient to address the full range of symptoms of depression. This has challenged the monoamine hypothesis, so the focus of research this year has shifted to possible abnormalities in the receptor system of neurotransmitters in patients.
3. Neuroendocrine dysregulation
It has long been thought that endocrine and depression are related to neuroendocrine regulation of many important acute hormones that affect sleep, appetite, sexual desire, and pleasure experience, among many other essential skills. It acts primarily through the hypothalamic pituitary adrenal system or HPA axis. The HPA axis in depressed individuals is mostly in a constant state of high arousal, and the excess hormones produced by high activity may have an inhibitory effect on monoamine receptors. Depression may develop as a result of neuroendocrine disorders caused by the body under prolonged stress, which leads to altered monoamine neurotransmitter function in the brain, and symptoms of depression may follow (Weiss, 1991).
V. The integrated view
Each of the above genres has offered its own explanation for the causes of depression. We believe that depression develops for a variety of reasons and that each patient has their own focused causes. Cognitive theory, behaviorism, humanistic existentialism and biological perspectives all explain depression to some extent, and each factor plays a role in the onset of depression. Therefore, it is important to examine the specific causes of each client for each individual.
Treatment approaches
Based on the different schools of thought on the causes of depression, they each propose their own treatment approaches. Current clinical data suggest that the use of psychotherapy combined with medication is the most effective treatment for depression. While antidepressant medication typically relieves 60-70% of symptoms of depression, psychotherapy appears to be equally good, with patients using psychotherapy alone also getting 60-70% of their symptoms relieved, and biological studies have shown that medication and psychotherapy can lead to similar chemical changes in the brain. However, the best treatment modality has been shown to be a combination of both, with patients who use both medication and psychotherapy achieving 80-90% symptom improvement. The following is a description of several of the main treatments currently in use.
I. Psychotherapy
1.Cognitive therapy
Cognitive therapy aims to adjust the inherent, negative and despairing thinking characteristics of depressed patients. Therapists in cognitive therapy want to help patients change their consistently distorted perceptions of reality and help them develop more objective and effective thinking structures. The therapist will first help the patient recognize their habitual negative automatic thoughts, and they will explain to the patient how these thoughts relate to depression. In a second step, the therapist will guide the patient to question these thoughts in order to develop new, more positive ways of thinking. For example, a depressed person may think that if they don’t do their best, they will accomplish nothing. Or they may think they may have an incurable disease whenever they are slightly unwell. Cognitive therapy hopes to change these perfectionist, good-or-bad, overblown cognitive distortions and create an objective and realistic structure of thinking. Typically the therapist hopes to help the patient achieve a set of milestones over a period of 6 to 12 weeks, and hopes that these results will help the patient solve some real-world problems.
Cognitive therapy is widely supported by empirical research, which shows that it is effective in treating depression, and that it performs as well as antidepressants, with both being effective in 60-70% of depressions.
2. Behavioral therapy
According to the behaviorist theory of depression, behavioral therapy helps patients get more positive stimuli to eliminate the depressive state, and Fensterheim suggests ways to make patients learn to be happy again. First, the patient is asked to imagine a behavior that will satisfy him or her: for example, eating a nice meal or taking a trip. Then the patient must perform these behaviors and record the internal experience while performing them. Through repeated behavioral training, the patient will increase these positive stimuli and the self-experience of these positive stimuli will be enhanced.
In addition, relaxation therapy, and training in social interaction skills are often used by behavioral therapy therapists.
3. Interpersonal therapy
As a modern development of psychoanalysis, interpersonal therapy focuses on the roles that lead to the patient’s social life and the relationships that are most important to them. The theory of interpersonal therapy assumes that it is the patient’s important interpersonal relationships that are problematic, or their inability to accept their social role that causes the symptoms of depression. Based on this hypothesis, the therapist first helps the patient to recognize these problematic relationships and their own denial of their interpersonal role. The therapist will then help the patient to work on adjusting these relationships or to get rid of the effects of these poor relationships. The therapist also helps the patient to reconceptualize his or her expectations of social roles, to adjust his or her internalized view of social roles, or to shift and form new interpersonal roles.
Interpersonal therapy is, along with cognitive-behavioral therapy, two of the most effective psychotherapies. This therapy has been shown to be effective in treating depression, and this therapy can lead to recovery in 60-80% of depressed patients (interpersonal therapy can be used both as individual therapy and as group therapy.
4. Humanistic-Existential Therapy
Person-centered-existential therapists try to make patients realize that their depressive pain is a reaction to their true feelings, which stem from their inability to live authentically out of their own desires. The therapist expects the patient to experience themselves as they really are and to find their way in life. A significant number of patients come to the therapist with questions about the meaning of their lives, and helping them to reconnect with this question, to find meaning in their lives, and to build a self-transcendent solution can often be very effective.
Rogers believes that it is the therapist’s attitude rather than the therapist’s technique that cures the patient, and he proposes a series of psychotherapeutic principles to listen to the depressed patient through empathic understanding and unconditional positive regard. While the depressive is trapped in his own suffering, he creates a “presence” or “accompaniment” of others. Rogers saw psychotherapy as a helpful interpersonal relationship, and it is this relationship that heals the patient. In such a relationship, the patient can find the right direction on his or her own, without the involvement of the therapist. The therapist-patient relationship advocated by Rogers has been widely accepted and used in a variety of therapies. The name he created, “the visitor” (to refer to the patient more intimately and respectfully), has also been widely accepted.
5. Group therapy
It can be said that group therapy and integrative therapy is a major trend in psychotherapy in recent years. It can be said to be a kind of interpersonal therapy. A group is equivalent to a miniature society, and the coping and thinking styles of group members can usually be well expressed in the group, and through comparison with others, patients themselves can more easily find their own problems or differences between themselves and others. Group therapy also helps patients train and improve their social skills, and group members can encourage, support, and inspire each other, providing a powerful forum for self-exposure. Another important advantage of group therapy is the low cost of group therapy, as each individual patient pays much less than for individual therapy to participate in group therapy.
Group therapy can be easily integrated with other therapeutic approaches, such as cognitive-behavioral therapy and humanistic presence therapy, which can be used in group therapy.
6.Morita Therapy
Morita therapy has been widely welcomed in China as an original Eastern psychotherapy method. The philosophy of Morita therapy is “let nature take its course, do what is right, and let the facts be true”. Morita believes that the patient’s symptoms are caused by the fact that he or she often lets his or her feelings go, and that they are severely detached from the objective facts. Morita therapy advocates accepting one’s own feelings, not fighting against them, and not caring too much about them, recognizing that they are only the patient’s own feelings. After a period of time, you will be able to recognize these unreal feelings and they will naturally subside.
Morita therapy has a strong tendency to be a cognitive-behavioral therapy, and the initial practice of bringing patients together is also group therapy in nature.
7. Integrative therapy
Just as there is no single cause of depression, treatment approaches are increasingly reflecting a tendency to integrate various schools of thought. It has even been suggested that for each unique individual, a specific treatment approach can be proposed for the individual, and this therapy is actually an integration of these mainstream psychotherapies. I also tend to integrate various therapies in my daily outpatient treatment, and different therapies should be adopted for different people and different problems.
II. Pharmacotherapy
The first-line medication currently used for antidepressant treatment is a drug called 5hydroxytryptamine reuptake inhibitor (ssri), which was invented in the late 1980s and has become popular due to its rapid onset of action, high safety profile, and low side effects since its introduction. As a result, the older generation of tricyclic and tetracyclic antidepressants are rarely used, except for the newer generation of drugs that cannot be afforded for economic reasons. The combination of medication and psychotherapy has become mainstream in the treatment of depression. Medication can rapidly improve most of the symptoms of depression, rebalance the nerves, and protect the body from long-term stress damage. Helping patients to reintegrate into real life and ensuring a normal work life is in itself a treatment for depression. Medications are essential in the treatment of depression and have an irreplaceable role to play. Many patients are influenced by the traditional concept of “medicine hurts the body” and “medicine is poisonous”, so they have certain prejudice against medication, which we do not want to see and is not beneficial to the treatment.