Examination of Depression and Treatment

Depression is an often-devastating symptom and illness in people. It affects millions of people worldwide and can last anywhere from week to months to years. People often have issues with depression and seek treatment. When they do, they do not adhere to treatment protocols and may regress back into depressive episodes. There are also situations and history that may attribute to the feelings of depression such family history, tragic events, job loss, or other high-stress events that bring an abrupt and uncomfortable change in a person's life. All these things will be discussed through a theoretical lens as well as introducing populations that may become more affected by depression than others are.

Many consider depression the "common cold" of mental illness. Depression is so common that the majority of the human population will know or be related to someone that suffered from depression. However, even though depression is commonplace, most people are confused over what depression is and how it affects people. People may confuse depression for acute episodes of sadness and do understand the kinds of depression out there. There are several different types of depression from biological depression, to seasonal affective disorder (that only happens when there is absence of natural light). However, certain things are always experienced when a person has depression.

Some of the common symptoms are a persistent anxious, sad, or "empty" mood, feelings of pessimism or hopelessness. A depressed person may also feel worthless, helpless and guilty. The things a depressed person found pleasure in or took interest in no longer satisfies him or her. They may also experience oversleeping, insomnia, or early-morning awakening.

People that are depressed, especially long-term may overeat and thus experience weight gain, may eat less and experience weight loss. Numerous others will experience a decrease in energy and fatigue with a constant feeling of being in slow motion. Those with severe depression will also contemplate suicide. A person gender may also affect how a person experiences depression. Males for example, more often than females, feel restless and irritable and may be diagnosed with ADHD.

There are a myriad of problems (both mental and physical) stemming from depression. Some of the mental symptoms were covered but some of the physical can be digestive disorders, headaches, and chronic pain. They may be signs of depressive illness, a physical manifestation of depression. What regularly differentiates occasional bouts of sadness from depression is the level of severity of the symptoms aforementioned and the length of time a person experiences them. When depression begins affecting daily life and a person's work ethic, that is when depression becomes unmanageable and professional help is needed.

There are several theories that may help one understand what depression is and how it manages to seep into a person's daily life and affect them so intensely. It can range from negative coping mechanisms to tragic life events, to a mixture of the two, and even genetics. Some people for example, have brains that naturally produce an imbalance of essential chemicals in the brain like serotonin or dopamine that produce symptoms like depression. The important thing is to be treated and work hard to fix what causes the depression, which comes from becoming aware of being depressed and things that may have led to the depression.

Depression is a serious and severe disorder. However, most people cannot tell when someone is depressed or if they are depressed themselves. It can creep without anyone knowing. Depression can be gradual and often strikes in adulthood versus teenage years where frequent mood swings are normal during that age. Men, who frequently display their depression in external ways, may not be diagnosed as much as women leading to many cases of depression going unnoticed. This paper is meant to show the effects of depression, what may cause depression and differences in gender, race, sexuality, and income that may bring about depression earlier and more severe than in others.

Objects and relations theory as well as behavioral and cognitive theories will provide the backdrop to study depression, how it may form within the life of a person. Theorists like Fairbairn, Winnicott, and Bowlby will be highlighted to show how the theory of depression as changed and expanded throughout the years. Depression will also be examined from a neurobiological perspective and a treatment section will show what current research suggests to be effective treatment against depression.

Theoretical Perspectives

Winnicott

The first theoretical perspective that will be examined comes from Winnicott and his view on creative and depression. To begin, Winnicott was a student of Klein. Klein supervised him as he expanded his knowledge on mental illness. Throughout his studies, he retained belief within two positions: the depression position, which slightly differed from Klein's, and the paranoid-schizoid position. How Winnicott's position differed from Klein's was in his preferences towards a less pathological term. As a manner in which to normalize depression in relation to regular concern and sadness. He began expressing his viewpoint within his famous saying "there is no thing as a baby" (Winnicott, 1952, p. 99). This saying refers to the mother-baby dyad as an entity. The relationship served Winnicott as a basis for a diagnostic template from which a patient's early disruption could be discovered.

Winnicott sought to understand the origins of a feeling in terms of how a person connects to him or herself and to others as well as the person's relations to objects and what a person does to retreat for relaxation. He contends that an infant locates a path separate from absolute dependency on the mother figure to relative dependency through the passion of three stages. These three stages are:

1. absolute dependency

2. personalization

3. primitive object relating

Absolute dependency means the infant has no control over the environment and itself. The baby experiences unusual moments of self-awareness linked to emotions of great intensity like excitement of feeding or rage. During these moments, the mother must hold the infant empathically, giving the infant support of her own self, allowing the baby to feel its own ego is connected. During this process, infants develop trust within the maternal environment. Sleep then becomes a pleasurable return to a version of un-integrated self.

To have the ability to exist peacefully within the environment leads into the capability to be truly alone. The baby establishes an internal mirroring or a kind of internal environment from the mother's ability to care for it within the stage of absolute dependence. If there is any failure during this stage, it may lead to paranoid stages. In an ideal environment, the infant gradually develops a true self. Although some may see Winnicott's "true self" as a conceptual ideal, it does provide some incentive for exploration into the idea that the negative attitudes and coping mechanisms a depressed individual has later on in life can stem from failure of support during his or her infant years and that stage of absolute dependency.

The second stage, a scenario where the mother is "adapted," managing her own as wwell as her baby's body allows formation of a unit. In addition, the psyche becomes in-dwelling within the soma. Manifestations of this arise in satisfactory muscle development and good body co-ordination. Essentially, during this state, the infant develops a sense of its own physical truth. The infant knows what is outside, what is inside.

The third and final stage, primitive object relating is where Winnicott believed the ego capable of affecting its environment. It begins when an infant feels pleased in creating a satisfying object. The infant feels in a way, its creator of a world and projects a healthy and necessary omnipotence. From there, fantasy and reality correspond for the baby.

When the infant experiences failure in this stage, it is generally because the mother puts her own needs first. Such inadequacies lead to formation of a "false self" that becomes a caretaker for the infant's true self. Therapy aimed at fixing this kind of error attempts to unlock the repression experienced during this stage.

Some individuals who have experienced many failures in childhood develop a false self to conceal the failure true self. This repression is unlocked in therapy when an opportunity is given to the patient to become angry at the therapist's errors. As a result, stored anger is released; and the patient becomes able to reality test (Winnicott, 1956, p. 386).

Winnicott explains the false-self comes from the result of the infant's need to conform to outside expectations and demands rather than responding to spontaneous, natural needs of its real self.

When an infant complies in meeting mother's needs while not having his/her own gestures affirmed and mirrored, the breakdown of the suitable environment occurs and results in development for the infant of a false set of relationships. Meaning if a person continues to attempt to cope with the world without help, it will lead to amplified feelings of emptiness, boredom, despair and isolation, culminating in suicide.

A certain level of assertion and independence is needed in people suffering from depression and lack of it contributes to the person's self-worth and ability to confide and ask for help from others. People that suffer from depression, exiting within a mother-child relationship where his or her needs were not met, may resist the urge to even understand his/her true self and simply cope by adapting and forming a more compliant, "selfless" self that continually causes pain, stress, and grief within the individual.

Fairbairn

Fairbairn developed his own theory of depression that transformed the way people see the origins of depression. Instead of viewing relationships as the consequence of drive discharge, Fairbairn's theory viewed self-expression within relationships as the basis of all psychic functioning. In his eyes, the building of the self was the process of repression and splitting that was profoundly pathological. He also included history of attachments to provide an understanding of healthy development. Through his theoretical interpretations, new ways of comprehending several disorders like schizophrenia, obsession, paranoia, hysteria, and paranoia were formed. Although Fairbairn had little to say about depression, depression tends to generate certain bad habits that are obsessive, and make people paranoid.

Therefore, it is important to understand how he viewed mental illness to understand the result and the processes in depression. From what can be gathered from literature, Fairbairn derived most of his thought on depression from Melanie Klein. He never expressed a theory of depression characteristically his own. It is for this motivation that what Fairbairn has had directly to speak on the topic is not nearly as persuasive as the rest of his theory. Nonetheless, depression is a tremendously significant and universal issue that Fairbairn indirectly offers a great deal of understanding and interpretation.

There are two examples showing Fairbairn speaking on depression prior to the appearance of his critical "object relations based theories in the 1940s --a case study in 1936 (1952) and the paper on aggression in 1939 (1994b) -- he basically adopted the existing view that aggression and oral sadism were the main issues in the condition" (Rubens, n.d.). Just as Klein influenced Winnicott, she also influenced Fairbairn and his object relations theory, especially in the depressive position. However, there were some differences in interpretation of the positions and he instead saw these positions as fundamental patters of interactions that characterized an individual's relation to another. Therefore, object relations fueled his theory development versus drives.

Although he had some things to say concerning the depressive position, the schizoid position served as a universal and basic position. He viewed the schizoid position as the fundamental state of existence and the underlying of the entirety of human psychopathology. Therefore, to understand depression from the lens of Fairbairn, it is important to understand the schizoid position/schizoid phase and attachment experienced within that phase. In simpler terms the actions individuals perform like obsessing over things, having strong compulsions, being too attached to things and people, they are the main problems and depression is a result of these behaviors, giving higher importance to the actions versus the outcome (depression). The chicken is the schizoid position and the egg or the product is the depressive position. That is why Fairbairn did not realize the importance or connection of depression, which in actuality could be the chicken or the egg in that depression could fuel such behaviors and the behavior could fuel depression.

Fairbairn saw within the schizoid quandary a risk of loss of the thing (as well as of the self) irrespective of whether the person endeavored to love the thing or endeavored to deny that love, and consequently the outcome is a thorough impasse, which diminishes the ego to a level of utter ineffectualness. The ego becomes unable of expressing itself. Its very being becomes compromised. The characteristic effect of the schizoid state is a sense of senselessness or futility.

The sense of futility he described can be interpreted as depression.

Fairbairn's theory is not founded on a transferal of aggression or based on oedipal guilt. Rather, he viewed it as the state of powerlessness, hopelessness, and immobilization that stems from the person's inability to surrender his/her immutable and absolute hold on his/her interior objects within the face of actions that press for him/her to do so. In simplistic terms, depression comes from the inability to let go of old, destructive habits (being stubborn) even though the situation requires change. On another level, it signifies the common attempt to reject any change within the inner state of affairs.

Since Fairbairn had allocated depression to an unconnected stage of development, he had to develop another designation for it as it functioned on the schizoid level. However, his calling it something else does not change the fact that it is exactly what it truly is, depression. There is no reason hy depressive reactions cannot thus be applied directly to schizoid situations. Fairbairn allowed depression to be understood as a function across a far-reaching spectrum of developmental levels. "Fairbairn was correct to notice a distinct quality in the schizoid sense of futility that was unlike the manifestations of depression on later developmental levels; but he was wrong not to notice its underlying continuity with those other manifestations" (Rubens, n.d.).

Fairbairn also describes psychopathology as being in a closed system stating that attachment to a prior developmental level and refusal to move on to a new life stage is like attempting to split-off into a different subsystem and maintaining that subsystem through repression, thus creating the hopelessness and futility seen in depression.

Fairbairn arrived at the notion that existence as a structure within the self means existence as a split-off subsystem of the self, created and maintained by repression, and owing its existence to the self's inability to deal with some important aspect of its experience that it found intolerable. He termed the process of establishing such structures "schizoid," because the splitting and repression by which it is constituted invariably diminish the self's capacity for growth and expression, and are therefore pathological (Skolnick & Scharff, 1998, p. 224-225).

Bowlby

Bowlby also had his own theory of depression that was more clear and comprehensive than Fairbairn that focused on attachments. In fact, it was called theory of attachment and in it, he suggests children come into the world already programmed to form attachments in order to help them survive. Drawing upon Lorenz's 1935 study discussing imprinting, Bowlby believed attachment behaviors to be instinctive and can be activated through negative actions and emotions like separation and fear. Things like a baby crying or crawling are all survival mechanisms to achieve proximity to the mother/attachment figure.

The relationship experienced by the infant to the attachment figure can then serve as the basis for any and all future social relationships and in Bowlby's eyes, disrupting such a relationship could birth severe consequences. When the child does not feel security for example, from the attachment figure, that child may not feel secure enough to explore the world, and instead develop cautious attitudes and behaviors, stifling growth and development. Researchers in order to examine and analyze depressed people as seen in a 1993 study have used Bowlby's attachment construct to understand underlying processes. "The depressed subjects demonstrated an anxious pattern of attachment, characterized by either intense care-seeking in relation to their attachment figure or angry withdrawal from their attachment figure when their desire for security was frustrated" (O Pettem, 1993, p. 78). Attachment thus becomes an integral part of understanding depression within Bowlby's perspective.

The main points of Bowlby's theory of attachment begins with a child having an innate need/desire to attach to a main attachment figure. This means Bowlby believed there should me one main bond that the child saw as more important than any other bond. This is typically the bond of mother and child. He also adds and contends that the bond of the mother and child is somehow dissimilar altogether from any other relationship.

The nature of monotropy then means that a failure to begin or a breakdown of maternal attachment may lead to grave negative results, even a possibility of affectionless psychopathy. The second point is a child must receive ongoing care from the single most significant attachment figure for almost the first two years of a child's life. Therefore, in Bowlby's eyes, mothering was most critical in the first two years, especially the first twelve months. " ... continual disruption of the attachment between infant and primary caregiver (i.e. mother) could result in long-term cognitive, social, and emotional difficulties for that infant" (McLeod, 2015).

The third point in the theory is a description of the long-term results of maternal deprivation, which may include:

1. Reduced intelligence

2. Depression

3. Delinquency

4. Affectionless psychopathy

5. Increased aggression

The fourth point goes into short-term separation from attachment figures and feelings of distress. Bowlby explains it through three progressive stages. The first is protest such as child crying, screaming when parent leaves. The second is despair as the child stops protesting, appearing calmer though remaining upset. The child will then refuse all attempts for comfort, frequently appearing uninterested in anything and withdrawn. The third is detachment where the child will outright reject the caregiver as well as show signs of anger.

The fifth and last point is the child's attachment bond with their main caregiver leads to formation of an inner working model. This working model thus provides the child a warped understanding (if the relationship sours) of how the world works and what to expect from people and relationships. Bowlby's theory although not as compelling as the other theorists perspectives, allows for creation of a strong basis for what may cause behaviors and thoughts that often lead to depression such as bad relationships, eating disorders and so forth that may stem from that initial relationship of caregiver and child.

Neurobiology

Researchers have examined the neurobiological perspective of depression in recent years, showing the neurobiological effects depression has on the human brain. In a 2012 study, researchers examined depressive disorder and its effects on the brain. Palazidou states depressive disorder is a relapsing, long-term, condition correlated with high levels of mortality and disability. It has a neurobiological source, is related structural, and function brain abnormalities. "Dysregulation of the hypothalamo-pituitary-adrenal (HPA) axis reduces hippocampal volumes and prefrontal cortex (PFC) activity in depressed patients and disrupts homeostasis within the neurocircuit of depression. Antidepressant drugs increase brain-derived neurotrophin, restoring neuronal growth and activity and modulate interactions between the neurocircuit anatomical structures" (Palazidou, 2012, p. 127).

Literature does not determine however, if these abnormalities existed prior to depression, progress and worsen, or are fully reversible. The article continues to suggest Subsyndromal states promote relapse as well as progression to chronicity. Over two years crosses into long-term depression and long-term depression is common.

Long-term depression is more serious versus episodic depression with a strong correlation with more functional impairment as well as high comorbidity (respiratory and cardiac syndromes) (Atmaca & Yildirim, 2012). Those suffering from long-term depression suffer considerably more from social phobia plus benzodiazepine abuse. In addition, both their psychological and somatic well-being are impaired. Depression and comorbid anxiety have an unfavorable effect on the progression of each other. Meaning, pre-existing anxiety presents as a risk factor for future depression.

People with anxiety states are inclined to grow either depression alone or depression and comorbid anxiety as they develop through adulthood. "Depression alone and depression comorbid with anxiety is more persistent than anxiety alone over time and this applies to both threshold and subthreshold disorders" (Palazidou, 2012, p. 131). In terms of neuroanatomy, early research identifies the limbic system as playing a role within the experience of emotion. The PFC or prefrontal cortex is also another area within the brain that researchers believes is responsible in maintaining emotional stability.

The PFC, amygdala and mainly the hippocampus are brain structures identified as the most widely studied in connection to depression. Magnetic resonance studies highlight a decrease in brain volume of patients suffering from depression compared with patients who are healthy (Koolschijn, van Haren, Lensvelt-Mulders, Pol & Kahn, 2009). Some of these changes as seen in these studies is a decreased activity in serotonergic and noradrenergic neurotransmission, a drop in brain neurotrophins as well as hyperactivity of HPA axis in addition to the inflammatory response system. "These are associated with functional abnormalities and structural deficits within the cortico-thalamic-striatal-limbic neurocircuit disrupting the system balance. The PFC which is functionally and structurally impaired is not able to regulate the overactivity within the cortical/limbic regions, resulting in the clinical manifestation of the depressive syndrome" (Palazidou, 2012, p. 141). Essentially what this means is, depression, specifically long-term depression, can affect the level of neurotransmitters in the brain, resulting in decreased activity and mass within certain parts of the brain.