Depression: Theories, Neurobiology, and Treatment Approaches

Introduction to Depression

Depression is an often-devastating symptom and illness that affects millions of people worldwide and can last anywhere from weeks to months to years. People frequently struggle with depression and seek treatment, yet many do not adhere to treatment protocols and may regress back into depressive episodes. There are also situations and histories that may contribute to feelings of depression, such as family history, tragic events, job loss, or other high-stress events that bring abrupt and uncomfortable change to a person's life.

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 who has suffered from it. However, even though depression is commonplace, most people are confused about what depression is and how it affects people. They may confuse depression with acute episodes of sadness and may not understand the different kinds of depression. There are several distinct types, ranging from biological depression to seasonal affective disorder, which occurs only in the absence of sufficient natural light. Regardless of type, certain experiences are common across all forms of depression.

Common symptoms include a persistent anxious, sad, or "empty" mood, as well as feelings of pessimism or hopelessness. A depressed person may also feel worthless, helpless, and guilty. Activities that once brought pleasure or interest no longer provide satisfaction. Individuals may also experience oversleeping, insomnia, or early-morning awakening.

People who are depressed, especially over the long term, may overeat and experience weight gain, or eat less and experience weight loss. Many others experience a decrease in energy and persistent fatigue, with a constant feeling of being in slow motion. Those with severe depression may also contemplate suicide. A person's gender may also affect how depression is experienced: males, for example, more often than females feel restless and irritable and may be diagnosed with ADHD instead of depression.

There are a myriad of problems—both mental and physical—stemming from depression. Beyond the mental symptoms already described, physical manifestations can include digestive disorders, headaches, and chronic pain. What regularly differentiates occasional bouts of sadness from depression is the severity of these symptoms and the length of time a person experiences them. When depression begins affecting daily life and a person's work ethic, it becomes unmanageable and professional help is needed.

There are several theories that help explain what depression is and how it seeps into a person's daily life. These range from negative coping mechanisms and tragic life events to genetics. Some people have brains that naturally produce an imbalance of essential chemicals like serotonin or dopamine, generating depressive symptoms. The important thing is to be treated and to work toward understanding the causes of depression. This paper examines the effects of depression, what may cause it, and differences in gender, race, sexuality, and income that may bring about depression earlier and more severely in some populations than in others.

Object relations theory, as well as behavioral and cognitive theories, will provide the backdrop for studying depression and how it may form within a person's life. Theorists like Fairbairn, Winnicott, and Bowlby will be highlighted to show how the understanding of depression has changed and expanded over the years. Depression will also be examined from a neurobiological perspective, and a treatment section will present what current research suggests to be effective.

Theoretical Perspectives

The first theoretical perspective examined comes from Winnicott and his views on creativity and depression. Winnicott was a student of Klein, who supervised him as he expanded his knowledge of mental illness. Throughout his studies, he maintained belief in two positions: the depressive position, which differed slightly from Klein's, and the paranoid-schizoid position. Winnicott's position differed from Klein's in its preference for a less pathological term—one that would normalize depression in relation to ordinary concern and sadness. He famously expressed this viewpoint in his saying, "There is no such thing as a baby" (Winnicott, 1952, p. 99), referring to the mother-baby dyad as a single entity. This relationship served Winnicott as a diagnostic template from which a patient's early disruptions could be discovered.

Winnicott sought to understand the origins of 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 how a person retreats for relaxation. He contends that an infant finds a path from absolute dependency on the mother figure toward relative dependency through three stages:

1. Absolute dependency
2. Personalization
3. Primitive object relating

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

The ability to exist peacefully within the environment leads to the capacity to be truly alone. The baby establishes an internal mirroring—a kind of internal environment—from the mother's ability to care for it during the stage of absolute dependence. Any failure during this stage may lead to paranoid states. In an ideal environment, the infant gradually develops a true self. Although some may view Winnicott's concept of the "true self" as a conceptual ideal, it offers a basis for exploring how the negative attitudes and coping mechanisms a depressed individual develops later in life may stem from failures of support during infancy.

In the second stage, a "well-adapted" mother manages both her own body and her baby's, allowing the formation of a unit. The psyche becomes in-dwelling within the soma, with satisfactory muscle development and good bodily coordination. During this stage, the infant develops a sense of its own physical reality—understanding what is outside and what is inside.

In the third and final stage, primitive object relating, Winnicott believed the ego becomes capable of affecting its environment. It begins when an infant feels pleasure in creating a satisfying object, projecting a healthy and necessary sense of omnipotence. From there, fantasy and reality begin to correspond for the baby.

When the infant experiences failure at this stage, it is generally because the mother places her own needs first. Such inadequacies lead to the formation of a "false self" that becomes a caretaker for the infant's true self. Therapy aimed at correcting this kind of disruption attempts to unlock the repression formed during this stage. Some individuals who have experienced many failures in childhood develop a false self to conceal the fragile true self. This repression is unlocked in therapy when the patient is given the opportunity to become angry at the therapist's errors, releasing stored anger and regaining the ability to reality-test (Winnicott, 1956, p. 386).

Winnicott explains that the false self results from the infant's need to conform to outside expectations and demands rather than responding to the spontaneous, natural needs of its real self. When an infant complies with meeting the mother's needs while having its own gestures unaffirmed and unmirrored, the breakdown of a suitable environment occurs and results in the development of a false set of relationships. 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—potentially culminating in suicide.

A certain level of assertion and independence is needed in people suffering from depression, and lack thereof contributes to diminished self-worth and an inability to confide in or ask for help from others. People suffering from depression who existed within a mother-child relationship where their needs were unmet may resist understanding their true self and simply adapt by forming a more compliant, "selfless" self that continually produces pain, stress, and grief.

Fairbairn developed his own theory of depression that transformed how people understand its origins. Rather than viewing relationships as a consequence of drive discharge, Fairbairn's theory regarded self-expression within relationships as the basis of all psychic functioning. In his view, the building of the self was a process of repression and splitting that was profoundly pathological. He also incorporated the history of attachments to provide an understanding of healthy development, and through his theoretical interpretations, new ways of understanding several disorders—including schizophrenia, obsession, paranoia, and hysteria—were formed. Although Fairbairn had relatively little to say about depression specifically, depression tends to generate certain habits that are obsessive and paranoid in character, making his broader framework relevant.

It is important to understand how he viewed mental illness in order to understand the processes and results of depression. From available literature, Fairbairn derived most of his thinking on depression from Melanie Klein; he never articulated a theory of depression that was distinctively his own. Nonetheless, depression is a tremendously significant and universal issue about which Fairbairn indirectly offers a great deal of understanding.

Prior to the appearance of his critical object-relations-based theories in the 1940s, there are two examples of Fairbairn speaking on depression—a case study in 1936 (1952) and a paper on aggression in 1939 (1994b)—in which "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's object relations theory, particularly regarding the depressive position. However, Fairbairn interpreted these positions as fundamental patterns of interaction characterizing an individual's relation to others—meaning object relations, rather than drives, fueled his theoretical development.

Although he had some things to say about the depressive position, it was the schizoid position that served as his universal and foundational position—the basic state of existence underlying the entirety of human psychopathology. In simpler terms, the actions individuals perform—such as obsessing, having strong compulsions, or becoming overly attached—are the primary problems, and depression is a product of these behaviors. The schizoid position is the chicken; the depressive position is the egg. That is why Fairbairn did not fully recognize the importance or connection of depression, which could in actuality be either the cause or the result—depression can fuel such behaviors, and such behaviors can fuel depression.

Fairbairn saw within the schizoid predicament a risk of loss of the object (as well as of the self), regardless of whether the person endeavored to love the object or to deny that love. The outcome is a thorough impasse that reduces the ego to a state of utter ineffectualness. Its very being becomes compromised. The characteristic effect of the schizoid state is a sense of futility—which can be interpreted as depression.

Fairbairn's theory is not founded on a transference of aggression or oedipal guilt. Rather, he viewed depression as a state of powerlessness, hopelessness, and immobilization stemming from the person's inability to relinquish an immutable hold on interior objects in the face of pressures requiring change. In simpler terms, depression arises from the inability to let go of old, destructive habits even when the situation demands it—a refusal of change in one's inner state of affairs.

Fairbairn also described psychopathology as a closed system, in which attachment to a prior developmental level and refusal to move 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, pp. 224–225).

"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.).

Bowlby offered a theory of depression that was more explicit and comprehensive than Fairbairn's, centered on attachments. His theory of attachment suggests that children come into the world already biologically prepared to form attachments in order to survive. Drawing upon Lorenz's 1935 study on imprinting, Bowlby believed attachment behaviors to be instinctive, capable of being activated by negative experiences such as separation and fear. Behaviors like crying or crawling are all survival mechanisms to achieve proximity to the caregiver.

The relationship an infant experiences with the attachment figure serves as the basis for all future social relationships. In Bowlby's view, disrupting this relationship could produce severe consequences. When a child does not feel security from the attachment figure, that child may not feel secure enough to explore the world, and instead develops cautious attitudes and behaviors that stifle growth and development. Researchers have used Bowlby's attachment construct to examine depressed individuals: "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).

The main points of Bowlby's theory begin with the child's innate need to attach to one primary attachment figure—typically the mother—whose bond he considered dissimilar from all other relationships. The nature of this monotropy means that failure to establish or a breakdown of maternal attachment may lead to serious negative outcomes, including the possibility of affectionless psychopathy. Bowlby also argued that a child must receive ongoing care from this primary attachment figure for approximately the first two years of life. As McLeod (2015) summarizes, "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."

The long-term results of maternal deprivation, in Bowlby's framework, may include: reduced intelligence, depression, delinquency, affectionless psychopathy, and increased aggression. The theory also describes short-term responses to separation from the attachment figure through three progressive stages: protest (the child cries and screams when the parent leaves); despair (the child stops protesting and appears calmer, though remains upset, withdrawing and refusing comfort); and detachment (the child outright rejects the caregiver and shows signs of anger).

Finally, Bowlby argues that the child's attachment bond with the primary caregiver leads to the formation of an inner working model. This working model—particularly if the relationship is troubled—provides the child with a distorted understanding of how the world works and what to expect from people and relationships. Bowlby's theory, though perhaps less theoretically elaborate than those of Winnicott or Fairbairn, offers a strong foundation for understanding how early caregiver relationships may give rise to behaviors and thoughts—such as disordered eating or troubled relationships—that often underlie later depression.

Conclusion

Depression is a pervasive, universal condition that affects millions, if not billions, of people. Although differences exist in the way people experience and express its symptoms, the underlying reality remains the same: people lose ability, power, and hope when in the grip of depression. The best approach to treatment is to identify the cause of the depression and address the underlying behaviors that led to it. Theorists like Winnicott have identified attachments and relationships during infancy and childhood as origin points for unhealthy development leading into depression; however, more research is needed to truly understand the disorder in all its complexity.