Etiology of depression and evaluation of the treatments
Depression is becoming an increasingly prevalent mental illness in society and it can become quite serious if not treated. There have been different approaches to explaining the causes of depression and none have yet to be proven incorrect. The causes of depression are the basis of the treatments that are developed and there are quite a number of ways in which to treat it. This essay will attempt to give a description of the etiology of depression through the biological and behavioural approaches as well as an evaluation of the treatments.
The biological approach to explaining depression is that there is a chemical imbalance of the neurotransmitters located in the brain and it is this which will cause a person to be depressed. The way in which to treat this is through two ways: to take antidepressant medication or to undergo electroconvulsive therapy. These treatments are said to balance out the neurotransmitters and because of this the depression will be eradicated.
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The behavioural approach to describing depression is that the patient learns to be depressed because of a low rate of behaviour, the patient experiences bad outcomes from their actions, which is a type of punishment. If this constantly happens the patient will learn to give up and will no longer make an effort in their life. The way in which to treat this is through psychotherapy. The behavioural approach has developed different types of therapies such as "Positive Psychotherapy", group therapy, "Rational Emotive Behaviour Therapy" and "Cognitive Therapy".
Studies have been conducted to test the efficacy of these treatments and it was found that behavioural therapies are just as effective as biological therapies. Behavioural therapies are probably a better way to treat depression as they do not cause the physical side effects that biological therapies do.
Mental illnesses are diseases that affect the mind psychologically and can completely consume one's life. A mental illness should be taken seriously and if not diagnosed or treated early then the illness may have a fatal consequence on an individual's life. According to the World Health Organization, depression is one of the most common mental illnesses and affects up to 121 million adults and adolescents worldwide(Healey, 2006).
There are many types of depression such as major depression or bipolar depression. The diagnosis of different types of the disorder is based on the degree of severity that an individual experiences and the specific types of symptoms that the individual is experiencing. A person who suffers from depression can experience feelings such as persistentsadness, pessimism, guilt and a loss of interest or pleasure in activities that they once enjoyed (Docalavich, 2007). The thoughts and behaviour of an individual may also be affected and leave one feeling irritable, restless, having difficulty paying attention and to even contemplate suicide. Depression may also involve physical symptoms including a loss of appetite, trouble sleeping, fatigue, headaches and a number of other symptoms (Docalavich, 2007). From time to time these feelings can be normal for an individual to experience but if they last for longer than two weeks or have interrupted one's usual daily activities then it can be categorized as a mental illness and one should seek help to try and reverse these feelings either with the aid of medicine, a type of therapy or a mixture of both. Asdepression is becoming increasingly prevalent within society, I believe that it is veryimportant to understand the different views on the origin of depression and also the treatments of depression because we should all be aware of this illness so that we can identify whether or not a friend or relative may have a problem and encourage them to get treatment before it becomes a major obstacle in one's life. This essay will attempt to give a description of the etiology of depression through the biological and behavioural approaches and an evaluation of the treatments.
THE BIOLOGICAL APPROACH AND THE CAUSES OF DEPRESSION:
The biological approach of understanding behaviour is based on the assumption that, "All that is psychological, is first physiological" (Anon, cited in Hill 2001 pg.20). Meaning that our behaviour and feelings must all have a physical or biological cause. Another assumption of the biological approach is that all psychology should be investigated through the brain, nervous system, endocrine system and genes as these areas are the grounds for the ways in which we behave and feel.
Genes affect the inheritance of characteristics, from parent to child across many generations. In some circumstances there is a hereditary component that can be linked to depression. The biological approach assumes that the physical and psychological traits of a person can be explained by genetic and hormonal factors. The brain and nervous system are also components of the biological approach. The structure and function of the brain are studied in great detail, because they are thought to be directly related to psychological processes.
Neurotransmitters are vital to understanding behaviour; they are the substances which transmit signals between neurons. There are over forty types of neurotransmitters of which some of their functions are unknown (Weiten 2007). The six main neurotransmitters are acetylcholine (Ach), dopamine (DA), norepinephrine (NE), serotonin, gamma-amino butyric acid (GABA) and endorphins;these are all responsible for specific behaviours that are exhibited by humans. Every single neurotransmitter has a specific receptor site; the receptor site is located on the dendrite of the proceeding neuron. Specific neurotransmitters bind to these specific receptors, much like a lock and key, the neurotransmitter fits into thespecific receptor site so that the transmitter can deliver signals to other neurons. Those who suffer from depression are thought to produce an insufficient amount of two of the neurotransmitters, serotonin and norepinephrine, in the synapses in the brain (Hill 2001).
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Researchers have endeavoured to find how biochemical changes are responsible for depression. Janowsky et al. (1972, cited in Crane and Hannibal 2009) experimented with participants using a drug called physostigmine and found that the participants became extremely depressed and had suicidal wishes. The experiment suggests that certain types of drugs can induce depression and because of this, in some instances, depression may be caused by biochemical factors. Delgado and Moreno (2000, cited in Crane and Hannibal, 2009) also researched depression and found that in depressed patients the levels of serotonin and norepinephrine are abnormal.
STRENGTHS AND WEAKNESSES OF THE BIOLOGICAL APPROACH:
There is no right or wrong approach to the understanding of human behaviour and both approaches have strengths and weaknesses. An obvious strength for the biological approach is that it is highly scientific which makes it reliable and the practical applications have been very successful. However the biological approach is reductionist and only focuses on specific aspects to give meaning to the functional whole (Crane and Hannibal, 2009). This means that in order to understand the nature of complex entities then one must reduce them to simpler more fundamental things. The biological approach over-simplifies the complexity of physical systems and their interaction with the environment. It does not take into account anything other than physiology. This is a factor which limits the biological approach in that it cannot explain how mind and body interact.
TREATMENTS OF DEPRESSION THROUGH THE BIOLOGICAL APPROACH:
As discussed earlier, according to the biological approach the cause of depression is because of abnormal levels of neurotransmitters in the synapses of neurons. The neurotransmitters which are said to be responsible for depression are mainly norepinephrine and serotonin. Drugs are thought to be the most effective treatment from the biological approach because they balance the abnormal levels of the neurotransmitters that are said to cause depression. Antidepressant drugs are defined as drugs that progressively elevate mood and help bring people out of depression (Weiten, 2007).
There are three main classes of antidepressants and they are tricyclics, Monoamine Oxidase Inhibitors (MAOI's) and selective serotonin reuptake inhibitors (SSRI's). These antidepressants all affect neurochemical activity in various ways and they do not all work in the same way. Tricyclics and MAOI's were the first two classes of antidepressants and it was found that tricyclics induce fewer side effects than the MAOI's (Potter et al. 2006 cited in Beck and Alford, 2006). The SSRIs slow the reuptake process at serotonin synapses which in turn increases serotonin activation (Hunter, 2007). SSRIs include 'Prozac' and 'Zoloft' and according to Shelton and Lester (2006 cited in Weiten, 2007), these drugs produce the same therapeutic benefits as the tricyclics.
Antidepressants are not the only type of treatment that the biological approach endorses; Electroconvulsive Therapy (ECT) is also a type of treatment. In the 1930's, it was thought that it would be helpful to induce seizures in those suffering from depression and schizophrenia and in 1938 Cerletti and Bini thought that it would be safer to bring on seizures with electric shock rather than using the drugs that were being used at the time. This theory resulted in the creation of ECT (Beck and Alford, 2006). According to Weiten (2007) ECT is a biomedical treatment in which electric shocks are used to produce a cortical seizure along with convulsions. In ECT a patient is anaesthetized and an electric current is transmitted to the brain by electrodes attached to the temporal lobes. This current triggers a convulsion for about 30 seconds and the patient usually wakes up after an hour or two. The electrical current has a disorganizing effect on the chemical activity in the brain and it is this disorganizing effect which is helpful as it is said to also restore the chemical balance of the neurotransmitters, thus improving the depressed individuals state (Yapko, 2002). Patients who receive this therapy usually receive between 6 and 12 treatments over a period of a month or more (Glass, 2001).
WEAKNESESSES IN THETREATMENT OF DEPRESSION THROUGH THE BIOLOGICAL APPROACH:
The biological approach has two main treatments for treating depression: antidepressants and ECT. It is estimated that 10-20% of patients will not respond to antidepressants. This could be because the patients are not taking the right dosage or taking the correct type of antidepressant (Docalavich, 2007). According to Montgomery et al. (1993 cited in Docalavich, 2007) SSRI's and tricyclics have a 65% success rate and the MAOI's have a 50% success rate. These are quite high numbers and although MAOI's are 50% successful they have more severe side effects as opposed to the Tricyclics and SSRI's. The side effects of MAOI's include liver damage, high blood pressure and may even cause death if mixed with the chemical tyramine which is found in common foods. There are many side-effects of tricyclics and "anticholinergic" is a term used to describe a range of symptoms brought about by them. The tricyclics block acetycholine receptors which affect the patient by creating a dry mouth, constipation andorthostasis(which is a significant drop in blood pressure when standing up suddenly). The drug can also interfere with the electrical conduction of the heart (Glick, 1995). SSRI's have fewer side-effects than other types of antidepressants: approximately 20-40% of patients develop gastrointestinal problems including nausea and vomiting (Glick, 1995). Insomnia may also be another side-effect that develops in patients using SSRI's. The more common symptoms that develop include headaches, dry mouth and a decreased appetite (Glick, 1995). According to Glick (1995) the way to deal with the side-effects of both tricyclics and SSRI's is to decrease the dose, then gradually increase it rather than stop the medication altogether.
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ECT is a controversial type of treatment for depression because of a few different factors. Critics argue that ECT is used too much and that it is a profitable procedure for the psychiatrists who administer the treatment because it increases their income and does not consume much of their time as opposed to therapy (Frank, 1990). The rate of relapse among the patients who receive ECT treatments is 50% within 6-12 months following the treatment. It is said that it can be reduced by giving ECT patients anti-depressants (Sackeim et al. 2001). There are many side-effects associated with the use of ECT and these consist of temporary memory loss and cognitive deficits (Lisanby et al., 2000; Sackeim et al. 2007). According to Glass (2001) these effects are slight and generally fade away after a short time. It has not yet been discovered why ECT could be effective in the treatment of depression but advocates believe that the seizure induced from ECT affects the imbalance of neurotransmitters in the brain, though the evidence that verifies this view is incomplete, inconsistent and inconclusive (Abrams, 1992). The use of antidepressants and ECT have differing side effects even though they both aim to balance out the imbalance of neurotransmitters which is said to be the cause of depression according to the biological approach. SSRI's and Tricyclic drugs are a better option to use as opposed to MAOI's; I say this because the side-effects of MAOI's are more severe than the side-effects of SSRI's and Tricyclic drugs. If the anti-depressants are not effective in treating depression then ECT should be the next alternative from the biological approach. This is because the way in which ECT actually works in treating depression has not yet been fully understood, so it should be a last resort and used only in the most extreme case as the side effects are quite severe and the initial symptoms that the individual experienced may be substituted with a side-effect which may be more difficult to deal with such as memory loss.
THE BEHAVIOURIST APPROACH AND THE CAUSES OF DEPRESSION:
The pioneers of behavioural psychology include Ivan Pavlov, JohnWatson, Burrhus Frederic (B.F) Skinner and Martin Seligman. These theorists base their understandings of the human psyche on the premise that all behaviour is learned from the environment and therefore studies within psychology should focus only on observable behaviour.
Pavlov (1906, cited in Weiten, 2007) conducted the experiment to research classical conditioning. Classical conditioning is one of the most well known theories of the learning perspective and it assists in understanding the origin of phobias and certain behaviours. Pavlov discovered that dogs learn to link the sound of a bell with food, and salivate when the bell is presented even when the food is not presented to them. This became known as "classical conditioning" and is also used to explain specific behaviours of human beings.
Operant conditioning is another way in which depression can be explained. Skinner was the behaviourist who unearthed operant conditioning and it is explained as a specific type of behaviour followed by a consequence, positive reinforcement, negative reinforcement or punishment, which in turn will either compel the organism to repeat this behaviour or avoid this behaviour depending on the reinforcement or punishment that the individual receives (Weiten, 2007). Operant conditioning can be applied to depression in that the individual is said to suffer from a lack of positive reinforcement which can lead to sad behaviour and when noticed may be reinforced by the attention that it attracts from those in the individual's social circle (Hill, 2001).
The behaviourist approach does not incorporate merely one aspect of behaviour but both behavioural factors as well as cognitive factors are taken into consideration. This movement can be attributed to Bandura, a behaviourist, who rejected Skinners deterministic operant theory and believed that internal mental processes and not just the environment play a part in determining behaviour (Weiten, 2007). Bandura is famous for his social learning theory, which he now calls social cognitive theory because it incorporates cognitive views. The social cognitive theory suggests that individuals can learn behaviour through observation rather than personal experience and that reinforcement is not required for learning to occur (Hill 2001 pg.75). The cognitive approach is based on the assumption that internal mental processes are vital in the understanding of human behaviour. This essay will incorporate cognitive-behavioural treatments as well as those treatments that have stemmed purely from the behaviourist approach.
Seligman and Maier (1967 cited in Seligman 1992) discovered what is known as"learned helplessness". They investigated this idea by experimenting on dogs. This experiment was conducted as a consequence of Skinner's research into reinforcement. Seligman exposed dogs to inescapable random electric shocks(punishment). Then these dogs were given trials of signalled escape-avoidance training, where the dog would have two compartments and would have to jump into the other compartment to escape the shock. Seligman and Maier tested 150 dogs with this methodology and found that two-thirds of these dogs gave up because they felt that they could not escape the shocks; they learned to be helpless (Seligman, 1975). Seligman claimed that the behaviour that the dogs had shown was similar to the behaviour of depressives (Hill 2001 pg.211). Seligman incorporated a cognitive aspect into his findings and suggested that people become depressed when they believe that there is nothing that they can do to ease their situation (Hill 2001 pg.211).
Lewinsohn, Youngren and Grosscup (1979, cited in Antonuccio) suggest that depression is a low rate of behaviour and this is caused by a lack of reinforcement from the environment. If an individual cannot undo the negative balance of reinforcement an intense state of self awareness will be a result of this which may lead to behavioural withdrawal and self-criticism (Lewinsohn, Hoberman, Teri and Hautzinger 1985 cited in Antonuccio).
STRENGTHS AND WEAKNESSES OF THE BEHAVIOURIST APPROACH:
The behaviourist approach has strengths in that its practical applications have been very effective and that it takes into account the environment and experiences of an individual to determine their behaviour. However, the weaknesses outweigh the strengths because its approach is reductionist, much like the biological approach, in that it relies on animal research which understates the fact that there is a considerable difference between humans and non-humans. Lastly the behaviourist approach generally overlooks the significant mental processes involved in learning.
TREATMENTS OF DEPRESSION THROUGH THE BEHAVIOURIST APPROACH:
The behaviourist approach in treating depression differs to that of the biological approach because their premise on the origin of depression differs and this is important in discovering effective treatments for mental disorders. The behaviourist approach has a few different types of treatments developed by different behaviourists. Based on Seligman's learned helplessness theory, Seligman developed what he terms as "Learned Optimism" and what is also known as "Positive Psychotherapy". This treatment is one whereby therapists attempt to get clients to recognize their strengths, appreciate their blessings, to appreciate their positive experiences, to forgive those who have wronged them and also to find meaning in their lives (Weiten, 2007).
Another behavioural approach to treating depression is known as a course named "Coping with Depression" which is derived from Lewinsohn's theory: depression is a result of a stressor. The "Coping with Depression" course is one whereby depressed individuals are taught strategies to help them cope with the problems that are thought to be associated with their depression. The types of strategies that are taught to patients include improving social skills, increasing pleasant activities, dealing with "depressogenic" thoughts and relaxing techniques. The course consists of 12 two-hour sessions which take place over 8 weeks. The course makes use of texts for the depressed individuals which includes "Control Your Depression" (Lewinsohn, Munoz, Youngren and Zeiss1986, cited in Antonuccio 1998) and a participant workbook (Brown and Lewinsohn 1984, cited in Antonuccio 1998). After the 12 two hour sessions there are two follow up sessions: one month later and then six months later. This encourages the maintenance of the gains of the treatment and also aids in gathering information on whether or not the individual's state has improved. If their state has not improved then booster sessions can be built to prevent this relapse from occurring again.
As mentioned earlier, the behaviourist approach incorporates cognitive views to assist in understanding and treating depression. Albert Ellis's "Rational Emotive Behaviour Therapy" (REBT) is based on the idea that it is not the events in our lives that upset us but rather the beliefs we hold which cause us to become depressed (Rational Emotive Behaviour Therapy Network 2006). REBT involves the identification of generalised irrational and false beliefs that are held by the patient and the therapist then uses forceful techniques to convince the patient to change these beliefs to more rational ones (Hill, 2001). Aaron Beck's "Cognitive therapy" is similar to that of Ellis's therapy in that it aims to identify and change the patient's negative thoughts about various aspects in their life. This therapy involves challenging the patient's beliefs and allows them to discover their dysfunctional beliefs for themselves (Hill, 2001).
WEAKNESESSES IN THE TREATMENT OF DEPRESSION THROUGH THE BEHAVIOURIST APPROACH:
Behavioural therapies are commonly criticised for being superficial, because they only focus on the patient's present experiences rather than their past experiences (Alloy, Acocella and Bootzin 1996). Behaviour Therapy is said to only address the symptom rather than the underlying cause so that even if the patient has been relieved of their symptoms there may be a time later on in their life when they are faced with another symptom that may be worse than the previous symptom because the underlying conflict was not dealt with. This is called "symptom substitution" (Alloy, Acocella and Bootzin 1996).
Seligman's "Learned Optimism" or "Positive Psychotherapy" is quite a new phenomenon and there have not been any studies that have been conducted to test the effectiveness of this type of therapy.
Lewinsohn's "Coping with Depression" course is a type of group therapy and group therapy has a few factors which a patient should consider before taking it on. These factors may be categorized as strengths or weaknesses depending on the type of patient who receives the therapy. In group therapy the patient should be no different to the rest in that there needs to be a sense of "belonging" in the group and no patient is to feel as though they are an "outsider" (Crane and Hannibal, 2009). This factor may be difficult for some depressed patients as depressed patients usually withdraw themselves from society. However, this may also be considered a strength as it is an opportunity for these patients to take the first step into making their way back into society. The patients who receive this treatment must be able to feel that they can speak freely in the group so that they can be completely honest with the therapist and benefit from this treatment (Crane and Hannibal, 2009). It is said that Group Therapy is not for everyone and that those patients who suffer from severe psychological stress should avoid this type of therapy (Alloy, Acocella and Bootzin 1996).
A major objection to cognitive-behavioural treatments (CBT and RET) is that the identification of the irrational views that a patientholds, which is said to be the cause of depression, is not enough to induce therapeutic change as events in life may not always be rational enough to explain (Alloy, Acocella and Bootzin 1996).In cognitive-behavioural treatments the therapist makes judgements about whether or not the patient's thoughts are acceptable. This point raises an ethical issue as it may not be appropriate for the therapist to make this judgement (Crane and Hannibal, 2009). Cognitive behavioural therapies require a high degree of commitment and honesty and if the patient is not willing to give this type of commitment and honesty then the therapy will not be effective in the treatment of their depression (NHS Choices 2010).
STUDIES THAT HAVE BEEN CONDUCTED TO TEST THE EFFECTIVENESS FOR THE TREATMENT OF DEPRESSION:
As described earlier, there are many weaknesses in the treatments of depression through both the biological and behavioural approaches. These factors need to be taken into account in order to thoroughly evaluate which approach to treating depression is most effective.
There are quite a few treatments that have been developed by the biological and behavioural approaches and it can be quite difficult to identify which treatment is more effective. Many studies have been conducted to aid us in the understanding of treating depression and so to discover which treatment is more effective, this section of the essay will go through some of the studies of treatments through the biological approach and behavioural approach so that we can come to a conclusion as to which treatment is more effective.Before proceeding, a point that needs to be noted is that in any experiment conducted there may be various factors that influence the outcome, such as experimenter bias or flaws in the procedure.
Wilson (1982 cited in Antonuccio, Danton and DeNelsky) conducted a study whereby 97 depressed patients were assigned to three types of psychotherapy (one of them being Lewinsohn's "Pleasant Activity Therapy" which is a part of the "Coping with Depression" course described earlier). All of the participants received some type of psychotherapy along with an antidepressant medication known as "amitriptyline" or a placebo for a two-month period. 64 patients completed the treatment and it was found that the "Pleasant Activity Therapy" and placebo was just as effective as the "Pleasant Activity Therapy" combined with "amitriptyline". Other studies suggest that similar behavioural interventions are as effective as combined treatments (Stravynski et al., 1984 cited in Antonuccio, Danton and DeNelsky). This study indicates that "Pleasant Activity Therapy" alone is quite effective on those who suffer from depression.
A study conducted by Hoberman, Lewinsohn and Tilson (1986) that contained 40 participants who met the "Research Diagnostic Criteria" for depressive disorders were treated with the "Coping with Depression" course. It was found that at the end of the treatment 85% of these participants no longer met the diagnostic criteria for depression. This study shows that the "Coping with Depression" course is quite effective in the treatment of depression. A factor that needs to be taken into account in any experiment that is conducted is that there may have been errors which mayhave occurred in the process. This experiment was carried out by a man named Lewinsohn who also developed the "Coping with Depression" course this may mean that there might possibly have been experimenter bias and the results were not accurate, this is a very important factor that should be taken into account as it will affect the results obtained.
A study conducted to compare the effectiveness of antidepressants and cognitive-behaviour therapy was performed by DeRubeis, Gelfand, Tang and Simons (1999) who set out to compare the results of antidepressant medication and CBT on depressed patients. These results were compared with results from a study conducted by the National Institute of Mental Health Treatment of Depression Collaborative Research Program to come up with treatment guidelines. It was found that CBT gave the same results as the antidepressant medication which means that CBT is an effective treatment for depression and it may be a better alternative as it will not result in some of the side effects that antidepressant medication may induce.
As the biological andbehavioural approaches to depression differ in their views on the causes it follows that the treatments of depression will also differ.Through this essay I have attempted to give a description of the etiology of depression through the biological and behavioural approaches as well as an evaluation of the treatments.
Through my research on this topic there are two main threads that I have identified: the first being that the biological approach seems to treat depression as though the locus of control is external, in that it addresses the symptoms but not the cause itself.
The second thread is contrary to that of the biological approach. Although the behavioural approach is generally based on the assumption that our behaviour is a result of our responses to stimuli, its locus of control in the treatment of depression is internal. This is because it addresses the cause of the patient's depression rather than the symptom.
After weighing up the evidence from the studies, it is indicated that behavioural therapies are just as effective as biological therapies, if not better, in treating depression. Although behavioural therapies may take time to be effective, they are better as they will not result in physical side effects which in themselves can cause different problems.However, for a quick response to an adverse situation such as a patient feeling a great urge to commit suicide (a possible side effect of depression) antidepressants may be a quick and effective solution with behavioural therapy as a follow up. As Crane and Hannibal state (2009) antidepressant medication and ECT can be quite effective in the treatment of depression as it may reduce symptoms but they do not ultimately constitute a cure.
Antidepressants can only be used to manage depression while the actual cure for depression would have to be through the approach taken by the behaviourists because the underlying conflict causing the depression is addressed. In the end, it is the way in which the patient responds to all forms of treatment which will prove its efficacy in the long run.
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