Symptoms, etiology and therapy of depression

The following article provides an introductory and hopefully easy-to-understand overview of the main symptoms, potential causes, and especially effective treatment and therapy options for depression.

Depression, as old as mankind, can be very stressful and distressing – but also a signal and an opportunity to change crucial things in life in a liberating and positive direction. A sustainable and trusting therapeutic relationship makes it possible to alleviate the subjective pressure of suffering and to regain quality of life for those affected and their relatives. Therapy always means work, reflection and confrontation with life and oneself, but it also provides perspectives and triggers inner processes that can direct perception and focus more towards the positive. Successful therapy should gradually create more serenity, autonomy and quality of life and, as the therapy process progresses, increasingly becomes a stabilizing and liberating self-therapy.

1. Characterization and symptoms of depression

Depressions or affective disorders are characterized by pathological changes in mood, i.e. emotions, with depressed, sad or even irritable moods. It is sometimes difficult to distinguish pathogenic moods from normal mood reactions – this requires a thorough clinical-psychological diagnosis. We are all familiar with “depressive mood phases” as normal reactions to stressful life events such as the loss of a loved one (mourning). Depression of a temporary nature can also occur during “role changes” such as the transition from study to a demanding career or from fulfilling work to retirement.

The term depression is derived from the Latin “depressio,” which means to depress. The leading psychological symptoms of depression include marked and persistent dejection, listlessness, perceived helplessness and hopelessness, and often unjustified feelings of guilt, as well as emotional emptiness and, in particular, reduced self-esteem. Activities and interpersonal encounters that were once enjoyable are rarely fun anymore, and people often withdraw from interpersonal contacts and social activities during depressive phases, making the depression even more intense.

In addition to psychological symptoms, depression is often accompanied by physical (somatic or vegetative) complaints such as, in particular, stomach and intestinal problems, difficulty falling asleep and staying asleep, physical restlessness and loss of libido. With prolonged depression, such physical discomforts carry the risk of increasing sensitization and chronicity. In addition, during depressive phases, there is also an increase in cognitive symptoms such as difficulty concentrating, a reduction in the ability to remember things and, above all, prolonged, circling and ultimately unproductive rumination. In depression, negative automatic thoughts and a cognitive triad with a pessimistic assessment of oneself, the environment and the future are very common.

This brief examination of depressive symptoms illustrates that depression can cause a great deal of suffering for those affected – as well as for their partners, relatives and those emotionally close to them.

A distinction is made between a depressive episode and recurrent depression, which is characterized by recurrent depressive phases with remission in between. For both forms, there are the severity levels mild, moderate and severe. Finally, there is a long-lasting type of depression, i.e. chronic, but less intense in its symptomatology (dysthymia).

Mania and bipolar disorder with alternation between phases of high spirits (mania) and depression is not addressed here.

The clinical-psychological diagnostic criteria for depression include at least four of the following ten symptoms, of which at least two of the first three symptoms must be present and the symptoms must be present for a minimum period of two weeks:

1. Depressed mood
2. Marked loss of interest or pleasure
3. Rapid fatigability and loss of energy
4. Loss of self-confidence
5. Inappropriate feelings of guilt and self-reproach
6. Suicidal ideation and behavior
7. Decreased concentration
8. Altered psychomotor activity (inhibited-slowed or agitated-restless)
9. Sleep disturbance (difficulty falling asleep and/or staying asleep, early morning waking)
10. Changes in appetite (with weight loss or even weight gain).

2. When do normal low moods become depressions?

As outlined, temporary periods of low mood do not necessarily meet the criteria of depression. The risk that depressive moods, which we all experience from time to time in the light of acute professional or private conflicts and/or critical life events, will become chronic and develop into a depression requiring treatment increases if:

• the depressive episodes increase in intensity, duration and/or frequency over time,
• one has experienced drastic and stressful life events such as job loss, violence and separation or divorce,
• one is unable to overcome the depressive phases on one’s own and feels a constant sense of being overwhelmed or overtaxed,
• negative professional and social consequences result, especially due to reduced ability to concentrate and withdrawal tendencies,
• the current life circumstances or life events cannot explain the extent of the depression (as a “normal reaction”).

In this case, you should consider supportive psychological-therapeutic counseling and treatment, the approach and possibilities of which are presented in the section “Treatment and therapy of depression”.

It should be noted that the current Covid-19 pandemic, with its inherent uncertainties and severe restrictions on social contacts, may cause (temporary) depressive symptoms in many people.

3. Prevalence of depression

There is empirical evidence that depression has increased in recent decades and continues to increase, but this is also related to higher awareness of psychological distress conditions. According to the 1996 World Health Organization (WHO) projection, depression will be the second leading cause of disease (after cardiovascular disease) by 2020. The cautious, i.e. rather low, estimated lifetime prevalence of depression in Europe is between 15 and 20 %, i.e. every fifth person suffers from depression once in a lifetime. Thus, depressed people are not at all alone, but they are often not aware of it and better psychoeducation is still needed.

4. Causes of depression

Depression is usually triggered and maintained by several factors – in technical terminology we speak of multifactorial etiology. The most important biopsychosocial causal factors are briefly outlined below.

 

4.1 Biological causes of depression

In addition to a genetic predisposition or vulnerability, potential biological causes include in particular neurobiological factors in the sense of an imbalance of messenger or neurotransmitter systems. Neurotransmitters such as serotonin, dopamine, norepinephrine and acetylcholine seem to be out of balance – compared to healthy individuals, depressed patients often show a reduced availability especially of serotonin and norepinephrine in the synaptic cleft between two neurons. The hypothesis of a dysbalance in neurotransmitter systems is supported by the general mechanism of action of antidepressants: Selective-serotonin reuptake inhibitors (SSRIs), in particular, have been shown to be effective and have a more favorable side effect profile compared with older tricyclic antidepressants.

It seems important to note that depression, like other mental illnesses, is generally first triggered by prolonged and increased stress when vulnerability is present, which is referred to as the diathesis-stress model. In the following, important psychosocial stressors are briefly highlighted.

4.2 Critical developmental factors and psychosocial causes of depression.

A critical developmental factor that may contribute to the development of depression is based on possibly misguided development in childhood. An over-protective and anxious-caring parenting style can lead to “learned helplessness” and undermine autonomy development and healthy stress coping.

Early loss of a parent, attachment disorder of the mother-child relationship, or low self-esteem since early childhood can also lead to excessive vulnerability to disappointment and low frustration tolerance. Finally, depression may result from unprocessed experiences of loss or trauma (e.g., sexual abuse, violence, and experience of catastrophe) or may promote the onset of a depressive episode in the event of renewed crisis situations (e.g., separation from a beloved partner).

In the broadest sense, the increased pressure to adapt, excessive pressure to perform at work and the disintegration of social structures, alienation in the light of digitalization, but also the tendency to “segregate” society can be subsumed under the psychosocial causal factors of depressive episodes.

Especially employees in internationally active industries (so-called expats) are now often required to be internationally mobile, which makes it difficult for some to maintain social networks, friendships and often even partner relationships in the long term. However, reliable social contacts and friendships as well as a stable partnership are an effective protection against depression, especially in times of increased stress or even in crisis situations.

4.3 Psychological cause theories of depression

The multitude of possible (further) psychological causal factors of depression shall be considered in more detail by explaining three theories in their main features and supported by short examples.

The psychodynamic theory sees depression as a failed mourning process due to an inwardly turned negative affect (e.g., long-lasting anger and hatred) as a result of the loss of a love object with which there was an ambivalent relationship. There is often a basic depressive conflict – especially between the desire for closeness and autonomy and between the fear of separation and the rage of disappointment – which can be processed and resolved in the course of a revealing therapy.

Depression represents a “regressive movement”, but it also has a protective function that is often overlooked. In a situation of perceived helplessness in the face of seemingly unsolvable conflicts, fear, or even shame, attachment to an entity that provides protection and security conveys a sense of safety.

The cognitive theory of dysfunctional cognitions and schemas (Beck, 1970) sees the causes of depression in distorted and dysfunctional cognitive processes. According to Beck, these are cognitive distortions that result from dysfunctional schemas and condition a negatively distorted perception of reality. Basic maladaptive cognitive patterns include depressed individuals’ negative and pessimistic attitudes toward themselves, their environment, and their future, which is referred to as the “cognitive triad.”

Unfavorable early childhood experiences and learning processes favor the acquisition of such negative schemas and beliefs, and corresponding negative automatic thoughts may be activated later in life when situations similar to the originating situation occur. Such automatic thoughts articulate themselves especially in distorted, inappropriate and generalizing false conclusions. An example of generalization: The (first-time) failure of a subject in a study leads to the fear that one could also fail all other subjects.

Typical cognitive errors, i.e., systematic thinking errors and faulty conclusions, which then in turn reinforce the negative schemas, are for example:

• Jumping to conclusions: Although given facts speak against it, one makes negative interpretations and conclusions. Example: “I don’t have the energy to go to the party and besides, I’m not welcome there anyway”.
• Catastrophizing: One is convinced that one’s development will be negative and no longer has access to the perception of positive developments and events. Example: “I failed the driving test the first time and will probably never pass it”.
• Absolutized dichotomous thinking: “black-and-white vision,” i.e., all experiences are classified into two mutually exclusive categories (e.g., flawless versus flawed, good versus bad). Nuances in between are hardly considered anymore. When a depressed client describes herself, she chooses the negative classifications and often deflects anything positive.

In the context of cognitive behavioral therapy, patients are given the tools to unlearn the negative automatic thoughts and pessimistic schemas outlined by means of cognitive restructuring, which is illuminated a bit in the section “Treatment and Therapy of Depression.”

Attribution theory, or pessimistic attribution style theory, views a depressive attribution style as a significant contributor to depression. It is based on the assumptions of Abramson, Seligman, and Teasdale’s (1978) reformulated learned helplessness theory.

According to this theory, the phenomenological experience of helplessness in the face of negative events depends on attribution or attribution style, i.e., attribution on the three dimensions of person (internal-external), stability (stable-instable), and globality (global-specific). The pattern of pessimistic attribution style is characterized by the tendency to interpret and explain negative events as internal, stable, and global.

Example: An attractive man who is rejected as a partner by a woman attributes this to his lack of attractiveness (internal, i.e., inherent in his own person), as stable (enduring), and global (affecting all women). As a consequence of his negative misattributions, his future expectations of success are also low, which can result in passivity and withdrawal tendencies.

Put simply, negative attributional styles and misattributions in turn condition negative effects on self-esteem and thus carry the risk of triggering and sustaining depression (Seligman, 1992).

Behavioral theories also attribute an important role to low social skills or abilities in the development and maintenance of depression.

In the context of cognitive therapy and cognitive-behavioral therapy, patients are given the tools to identify and reality-check negative misattributions and subsequently overlearn “learned helplessness,” as shown in the following section, “Treatment and Therapy of Depression.”

5. Treatment and therapy of depression

A number of evidence-based and effective treatment options for depression exist. After initial diagnostic clarification, the appropriate multimodal therapy is derived and a treatment plan is created for the patient. This is reviewed for its effectiveness as the therapy progresses and, if appropriate, modified.

 

5.1 Biological therapy methods for the treatment of depression

Biological treatment approaches fall into the psychiatric field and include treatment with psychotropic medical drugs, especially antidepressants. Most notable are selective serotonin/norepinephrine reuptake inhibitors (SSRI/SNRI), which prolong the availability of serotonin and/or norepinephrine in the synaptic cleft and are considered to be relatively well tolerated with a favorable side effect profile.

If pronounced sleep disorders, agitation, acute crises or suicidal tendencies are present, benzodiazepines (tranquilizers) may be indicated for short-term (!) drug intervention – short-term because these drugs have a high addiction potential! Tranquilizers are prescribed especially for short-term treatment of acute anxiety disorder.

However, pharmacotherapy alone is not advisable – it should always be supplemented by psychological-therapeutic treatments.

Electroconvulsive therapy (ECT) should be used as a generally effective therapy only in cases of extremely severe depression; its mechanism of action is still insufficiently understood.

Sport can be considered as an absolutely side-effect-free “biological self-therapy”. Moderate endurance exercise leads to a release of endorphins (self-produced, endogenous morphines), which also have a mood-lifting effect. If you then also practice sports with sociability – such as team sports, tennis or dancing – this also includes the possibility of positive social contacts and thus also represents an important psychosocial measure.

5.2. Psychosocial interventions for depression

Psychosocial interventions include the important social component, i.e., interpersonal interaction with the opportunity to make new acquaintances and friends. For younger people and middle-aged patients, sports and exercise have proven to be very helpful – for older patients, physiotherapy and spa stays are beneficial.

Since many depressed people have often shown a social withdrawal, the gradual resumption of social activities – also taking into account the changed resilience – is advisable. Under certain circumstances, the shyness towards interpersonal contacts even shows traits of a social phobia. In these cases, effective support and motivation by experienced clinical and health psychologists can be helpful.

5.3 Psychological and Psychotherapeutic Treatments for Depression

A variety of psychological and psychotherapeutic treatment approaches exist. Psychoanalytic and psychodynamic therapies, which are useful for certain forms of depression, will not be discussed in detail here. The (mindfulness-based) cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are described below.

5.3.1 Cognitive Behavioral Therapy for the Effective Treatment of Depression

Cognitive behavioral therapy (CBT) is a very effective and stress-reducing method for treating depression. Like any therapy, CBT is “self-help” – patients learn to use these treatment tools independently for adaptive cognitive, emotional, and behavioral self-regulation as therapy progresses.

Basic components of CBT include social and emotional skills training, perceptual training, identification and correction of negative self-evaluations, and especially the reduction of cognitive thinking distortions and misattributions. In addition, CBT also enables those affected to see and “use” their strengths and resources (again) – in depressive phases, the view of strengths and resources is severely restricted. As with all psychological stress conditions, the training of emotional competencies is also and especially important in depression – this stabilizes emotional self-regulation and improves it in the long term. In addition, there are important techniques for ending or reducing the widespread tendency to brood or ruminate – such as the “thought stop” or “brooding chair”. Finally, the gradual increase of activities and social contacts that were fun before the depression is also very crucial to salutogenesis.

In recent years, aspects of mindfulness have been incorporated into CBT – we then refer to it as mindfulness-based cognitive behavioral therapy. By mindfulness we mean a specific process of attention, which is intentional, focused on the present moment, and most importantly, non-judgmental. Mindfulness means to be in the present moment – in the here and now – to be aware, to be attentive, and not to judge or evaluate. Mindfulness is a technique that can be trained, and even more an attitude that can be learned. Mindfulness serves the acceptance of depression – so important at first – without devaluing and sabotaging oneself. Mindfulness can be practiced under psychological guidance through sitting and breathing meditations or the body scan, and complements the traditional relaxation techniques of progressive muscle relaxation, autogenic training, and tapping acupressure. Unlike relaxation techniques, however, mindfulness techniques also carry a component of spirituality.

5.3.2 Interpersonal psychotherapy

Interpersonal psychotherapy (IPT) is based on the assumption that inadequate adaptation to psychosocial stressors or inadequate coping with them is a key trigger of depression. In IPT, the therapist helps the patient identify, understand, and explain events that potentially triggered the depression. This may be the loss of a close person, or a painful separation. Role conflicts and role changes as well as social isolation or deficits in social competence and communication can also be considered as possible triggers. Thus, important therapy areas of IPT include, in particular, grief work, separation processing, adjustment to taking on new social roles, and working through possible interpersonal and social conflicts or “deficits.”

Designed as a short-term therapy with 15 to 20 sessions of 50 minutes each, IPT teaches patients helpful and stress-reducing techniques for coping with the loss of a loved one and/or separation from a beloved partner, resolving role conflicts, adjusting to role changes, and compensating for possible social skill and communication deficits.

IPT is, among other things, very helpful and effective for those affected:

• who have experienced stressful life events or life changes, e.g., a subjectively difficult transition from college to their first job or retirement after a long and successful career,
• who experience difficulties with a social role change, e.g., a mother whose only daughter leaves the shared household as she grows up,
• who experience interpersonal and insufficiently resolvable conflicts with people close to them,

who repeatedly display unfavorable relationship patterns.

6. Summary and résumé

Depression can occur in the form of a single depressive episode or recurrent episodes (relapsing). There is much evidence to suggest that the diverse professional and personal adjustment demands of our fast-paced times have favored the development and maintenance of depression. They are widespread today with a prevalence rate of up to 20  %, meaning that one in five will experience depression requiring treatment once in their lifetime.

The symptoms of depression are physical (vegetative) and psychological, with the leading symptoms of depressed mood, loss of interest, and reduced drive.

Looking at the causes, these are multifactorial and include biological, psychosocial and also life history components.

There are a number of effective psychological and psychotherapeutic treatment approaches, with psychodynamically oriented therapy but especially mindfulness-based cognitive behavioral therapy and interpersonal psychotherapy proving effective. This opens up stress-reducing ways for depressed people to cope with depression and paths to liberating salutogenesis. This shifts the focus back to the positive and paves the way from perceived helplessness to “learnable” optimism.

Ultimately, an initially accepting and metacognitive perspective can also be helpful in not letting the depression overwhelm you: “It’s not bad to be depressed, but it is bad to let it depress you, to be depressed at the moment.”

 

Depression often occurs together with an anxiety disorder (comorbidity).

Management and therapy of anxiety disorders.