216 CHAPTER 6
specifi c with only these two forms of treatment? Because the forms of treatment have
been studied the most extensively, and hence more is known about which specifi c
medications and CBT methods are most likely to reduce symptoms and improve qual-
ity of life. Rigorous studies of other types of treatments are less common, and hence
less is known about the specifi c methods that are most likely to be effective. You will
fi nd this same disparity in knowledge refl ected in subsequent fi gures that illustrate
feedback loops of treatments for other disorders.Now that we’ve discussed depressive disorders, let’s look back at what we know
about Kay Jamison thus far, and see whether MDD is the diagnosis that best fi ts her
symptoms: She experienced depressed moods, anhedonia, fatigue, and feelings of
worthlessness. She also had recurrent thoughts of death, as well as diffi culty concen-
trating. Taken together, these symptoms seem to meet the criteria for MDD. However,
she also has symptoms that may be building blocks for the diagnosis of another mood
disorder. If her symptoms meet the criteria for any of those building blocks, her diag-
nosis would change. We examine those building blocks in the next section.Key Concepts and Facts About Depressive Disorders
- A major depressive episode (MDE) is the building block for a
diagnosis of major depressive disorder (MDD): When a person
has an MDE, he or she is diagnosed with MDD. Symptoms of
an MDE can arise in three areas: affect (anhedonia, weepiness,
and decreased sexual interest), behavior (vegetative signs), and
cognition (sense of worthlessness or guilt, diffi culty concentrat-
ing, and recurrent thoughts of death or suicide). Most people
who have an MDE return to their premorbid level of functioning
after the episode, but some people will have symptoms that do
not completely resolve even after several years. - Depression is becoming increasingly prevalent in younger
cohorts. Depression and anxiety disorders have a high
comorbidity—around 50%. - MDD may arise with melancholic features, catatonic features,
or psychotic features. Symptoms may also fall into less common
patterns, as in atypical depression and chronic depression. In
some cases, depression is related to pregnancy and giving birth
(postpartum onset) or to seasonal changes in light (seasonal
affective disorder). - A diagnosis of dysthymic disorder requires fewer symptoms
than does a diagnosis of MDD; however, the symptoms of dys-
thymic disorder must persist for a longer time than do symp-
toms of MDD. People with both dysthymic disorder and MDD
are said to have double depression. - Neurological factors related to depression include low
activity in the frontal lobes, and implicate abnormal function-
ing of various neurotransmitters (dopamine, serotonin, and
norepinephrine). The stress–diathesis model of depression
highlights the role of increased activity of the HPA axis and
of excess cortisol in the blood; an overreactive HPA axis is
thought to affect serotonin activity and impair the functioning
of the hippocampus. People with atypical depression have the
opposite pattern—decreased activity of the HPA axis. Genes
can play a role in depression, perhaps by causing a person
to have disrupted sleep patterns or by influencing how an
individual responds to stressful events, which in turn affects
activity of the HPA axis.- Psychological factors that are associated with depression
include a bias toward paying attention to negative stimuli, dys-
functional thoughts (including cognitive distortions related to
the negative triad of depression), rumination, a negative attri-
butional style (particularly attributing negative events to inter-
nal, global, and stable factors), and learned helplessness. - Social factors that are associated with depression include
stressful life events, social exclusion, and problems with social
interactions or relationships (particularly for people who have
an insecure attachment). Culture and gender can infl uence the
specifi c ways that symptoms of depression are expressed. - Neurological, psychological, and social factors can affect each
other through feedback loops, as outlined by the stress–diathesis
model and Coyne’s interactional theory of depression. Accord-
ing to the stress–diathesis model, abuse or neglect during child-
hood (a stressor) and increased activity in the HPA axis can lead to
overreactive cortisol-releasing cells (a diathesis), which respond
strongly to even mild stressors. Psychological factors can create
a cognitive vulnerability to depression, which in turn can amplify
the negative effects of a stressor and change social interactions.
Coyne’s theory proposes that among neurologically vulnerable
people, their depression-related behaviors may alienate other
people, producing social stressors. - Biomedical treatments that target neurological factors for
depressive disorders are medications (SSRIs, TCAs, MAOIs, SNRIs,
St. John’s wort, and SAMe) and brain stimulation (ECT or TMS). - Treatments for depression that target psychological factors
include CBT (particularly with behavioral activation). - Treatments that target social factors include IPT and family
systems therapy.
continued on next page