Major
Depressive Disorder and Related Conditions
Everyone has days where they feel blah, down, or sad.
Typically, these feelings disappear after a day or two, particularly if
circumstances change for the better. People experiencing the temporary
"blues" don't feel a sense of crushing hopelessness or helplessness,
and are able, for the most part, to continue to engage in regular activities.
For people dealing with depressive disorders, negative feelings linger,
intensify, and often become crippling. With normal sadness, people are still
able to experience pleasure when positive events happen. With depressive
disorders, the hopelessness and failure stay even when good things are
happening. Other, more intense sorts of symptoms, such as suicidal thoughts and
hallucinations (e.g., hearing voices), are also often present. These symptoms
suggest that serious varieties of depression may be present, including the
subject of this center: Major Depressive Disorder (MDD) or (more
informally), Major Depression. Major Depression.
Major Depressive Disorder is a common yet serious
medical condition that affects both the mind and body. It creates physical
(body), psychological (mind), and social symptoms. Informally, we often use the
term "depression" to describe general sadness. The term Major
Depressive Disorder is defined by a formal set of medical criteria which
describe symptoms that must be present before the label may be appropriately
used.
Major
Depressive Disorder has been typically thought of as a mood disorder. The term
"mood" describes one's emotions or emotional temperature. It
is a set of feelings that express a sense of emotional comfort or discomfort.
Sometimes, mood is described as an extended or ongoing emotion that colors a
person's whole life and state of well-being. For example, if someone is
depressed, they may not feel like exercising. By not exercising for long
periods of time, they will eventually experience the negative effects of an
inactive lifestyle such as fatigue, muscle aches and pains, and in some cases,
other medical conditions like heart disease.
You
may have heard terms like in the past like Unipolar Depression, Bipolar or
Manic Depression, but these are separate and distinct disorders. During a
particular day or week, people can shift from good (or "up") moods,
to bad (or "down") moods, or remain somewhere in the middle
("neutral" mood). A person who experiences significant impairment
related to shifting between up and down moods often has bipolar disorder. Bipolar
disorder can be envisioned as a seesaw movement back and forth between two
poles or mood states ("bi" means "two"). In contrast to
people with bipolar disorder, people with MDD remain on the down side of the
pole; they do not exhibit mood swings. Because they are stuck on the down
or depressed end of the mood continuum; they experience a unipolar
("uni" means "one") mood state. It is important to note
that bipolar disorder or manic depression was originally described in the Major
Depression chapter of the DSM; however, with new research and better
understanding of the disorder, experts have now separated bipolar and its
related disorders from the depressive disorders in the DSM-5. Visit our bipolar
disorder center to learn more about that condition.
According
to the World Health Organization, depression is a common illness worldwide,
with an estimated 15% of people affected. These people can become disabled by
their condition and have problems going to school, work, and meeting their
other responsibilities. If they get to school and/or work, they may have
difficulty in their relationships with others. A stay at home caretaker such as
a mother may have hard time caring for her children and accomplishing daily
tasks. As such, daily suffering is not limited to the individual diagnosed with
MDD. Spouses, children, parents, siblings, and friends of people experiencing
MDD often experience frustration, guilt, anger, and financial hardship in their
attempts to cope with the suffering of their loved one.
Major
Depressive Disorder has a negative impact on the economy too. Depressive
disorders are a leading cause of absenteeism and lost productivity. Although
only a small number of people get professional help to relieve a depressive
disorder, people with depression are significantly more likely than others to
visit a doctor. Some people express their sadness in physical ways, and these
individuals may go through extensive and expensive tests and treatments while
their depressive disorder goes undiagnosed and untreated. As a result,
depression-related visits to doctors account for a large portion of health care
spending.
Major Depressive Disorder and Related Conditions
Everyone has
days where they feel blah, down, or sad. Typically, these feelings disappear
after a day or two, particularly if circumstances change for the better. People
experiencing the temporary "blues" don't feel a sense of crushing
hopelessness or helplessness, and are able, for the most part, to continue to
engage in regular activities. For people dealing with depressive disorders,
negative feelings linger, intensify, and often become crippling. With normal
sadness, people are still able to experience pleasure when positive events
happen. With depressive disorders, the hopelessness and failure stay even when
good things are happening. Other, more intense sorts of symptoms, such as
suicidal thoughts and hallucinations (e.g., hearing voices), are also often
present. These symptoms suggest that serious varieties of depression may be
present, including the subject of this center: Major Depressive Disorder
(MDD) or (more informally), Major Depression. Major Depression.
Major
Depressive Disorder is a common yet serious medical condition that
affects both the mind and body. It creates physical (body), psychological
(mind), and social symptoms. Informally, we often use the term
"depression" to describe general sadness. The term Major Depressive
Disorder is defined by a formal set of medical criteria which describe symptoms
that must be present before the label may be appropriately used.
Major Depressive Disorder has
been typically thought of as a mood disorder. The term "mood"
describes one's emotions or emotional temperature. It is a set of feelings that
express a sense of emotional comfort or discomfort. Sometimes, mood is
described as an extended or ongoing emotion that colors a person's whole life
and state of well-being. For example, if someone is depressed, they may not
feel like exercising. By not exercising for long periods of time, they will
eventually experience the negative effects of an inactive lifestyle such as
fatigue, muscle aches and pains, and in some cases, other medical conditions
like heart disease.
You may have heard terms like in
the past like Unipolar Depression, Bipolar or Manic Depression, but
these are separate and distinct disorders. During a particular day or week,
people can shift from good (or "up") moods, to bad (or
"down") moods, or remain somewhere in the middle ("neutral"
mood). A person who experiences significant impairment related to shifting
between up and down moods often has bipolar disorder. Bipolar disorder
can be envisioned as a seesaw movement back and forth between two poles or mood
states ("bi" means "two"). In contrast to people with
bipolar disorder, people with MDD remain on the down side of the pole;
they do not exhibit mood swings. Because they are stuck on the down or
depressed end of the mood continuum; they experience a unipolar
("uni" means "one") mood state. It is important to note
that bipolar disorder or manic depression was originally described in the Major
Depression chapter of the DSM; however, with new research and better
understanding of the disorder, experts have now separated bipolar and its
related disorders from the depressive disorders in the DSM-5. Visit our bipolar
disorder center to learn more about that condition.
According
to the World Health Organization, depression is a common illness worldwide,
with an estimated 15% of people affected. These people can become disabled by
their condition and have problems going to school, work, and meeting their
other responsibilities. If they get to school and/or work, they may have
difficulty in their relationships with others. A stay at home caretaker such as
a mother may have hard time caring for her children and accomplishing daily
tasks. As such, daily suffering is not limited to the individual diagnosed with
MDD. Spouses, children, parents, siblings, and friends of people experiencing
MDD often experience frustration, guilt, anger, and financial hardship in their
attempts to cope with the suffering of their loved one.
Major Depressive Disorder has a
negative impact on the economy too. Depressive disorders are a leading cause of
absenteeism and lost productivity. Although only a small number of people get
professional help to relieve a depressive disorder, people with depression are
significantly more likely than others to visit a doctor. Some people express
their sadness in physical ways, and these individuals may go through extensive
and expensive tests and treatments while their depressive disorder goes
undiagnosed and untreated. As a result, depression-related visits to doctors
account for a large portion of health care spending.
Although the causes of depression
are not yet fully understood, we do know that there are a number of factors
that can cause a person to suffer from depression. We also know that people who
are depressed cannot simply will themselves to snap out of it. Getting better
often requires appropriate treatment. Fortunately, there is a wide number of
effective treatments available.
This center provides an in-depth
look at Major Depressive Disorder by summarizing symptoms and diagnostic
criteria according to the current standards, prevalence and course, historical
and contemporary understandings of the causes of the condition, as well as
diagnosis and treatment.
Classic Symptoms of
Major Depressive Disorder
The American Psychiatric
Association (APA) publishes the Diagnostic and Statistical Manual of Mental
Disorders (DSM). This manual describes the symptoms necessary for the diagnosis
of all mental disorders, including Major Depressive Disorder. The DSM is
updated when research and changes in the medical system make it necessary to
revise old diagnoses. For example, in the last edition of the DSM, bipolar
disorder was classified under MDD. In the most current edition (DSM-5), bipolar
disorder is now a completely separate diagnostic category.
The Depressive Disorders category
now includes:
· Major
Depressive Disorder
These conditions are all similar
in that they all have something to do with having a depressed mood. They are
separated by the severity of the depression or by what may be causing it.
A
person is diagnosed with Major Depressive Disorder when:
· they
experience five or more of the following symptoms
during the same two-week period for most of the day or nearly every day:
o Feelings
of sadness, emptiness, or hopelessness (in children, this may be irritability)
o Having
no interest or feeling no pleasure in all or almost all activities
o Weight
loss or weight gain by greater than 5% when not trying to lose or gain weight
OR a change in appetite nearly every day
o Sleeping
too little or too much
o Physical
agitation or restlessness that is observed by others
o Being
tired and having a lack of energy
o Feelings
of worthlessness, self-hate, and guilt
o Not
being able to concentrate, think clearly, or make decisions
o Being
irritable
o Ongoing
thoughts of death or suicide - either thinking about suicide without a plan for
how it would happen, having a specific plan or attempting to commit suicide
· Never
having a manic or hypermanic episode (being very excited or energetic which
would be possible symptoms of bipolar disorder)
· these
symptoms cause a great deal of stress in the person's life or cause changes in
their daily activities such as not being able to get out of bed, getting ready
for the day, and/or handling school, work, relationships, and other commitments.
· at
least one of the symptoms is depressed mood or loss of interest or pleasure
Depression and Moral Health
S. Nassir Ghaemi said "Neurologists are sometimes
accused of admiring disease rather than treating it," psychiatrists seek
to cure disease even when they do not understand it. At the same time, he
notes that
Freud had both theoretical and practical interests that occasionally point in
different directions, and psychiatrists have learned that theoretical
understanding of the sources of suffering does not always translate directly
into useful clinical practice. For their part, philosophers are often
criticized for indulging in
armchair speculation that yields neither empirical
understanding nor practical efficacy.”
Writing as a philosopher in "Depression:
Illness, Insight, and Identity," I had hoped to engage both scientific
and therapeutic interests while linking them to
humanistic concerns about values. Ghaemi's emphasis is
primarily therapeutic--to help, to heal--but he seems
generally sympathetic to my goal of integrating moral and therapeutic
perspectives.
My paper is part of a larger project of interweaving
morality and therapy as applied to an array of human problems, or rather of
elaborating on an integration that has already evolved in our society, and
which now permeates self-help literature, talk shows, sermons, and much
psychotherapy (Martin 1999b). This integration resonates with Plato's daring
intuition in Republic that morality and mental health are fundamentally
linked through a concept of moral health.
Moral health is something more than a
metaphor. It refers to active capacities that are essential for both moral life
and psychological coping. But Plato went too far when he equated virtue and
mental health: "Virtue is as it were the health and comeliness and
well-being of the soul, as wickedness is disease, deformity, and weakness"
(1945, trans.Cornford). So did humanistic psychologists, such as Erich Fromm,
who attempted to derive
moral principles from psychological facts (1947).
Certainly we must not make moral judgments about dementia, consider episodic
wrongdoing simply pathological, or lapse into the patronizing notion that the
higher reaches
of moral commitment are merely signs of sound health.
Nevertheless, I am convinced that Plato glimpsed a larger truth than his
critics allow (Kenny 1973).
Certainly we need to dissolve any rigid dichotomy
between moral and therapeutic perspectives on depression, while still
appreciating that different practical purposes warrant different emphases. Two
powerful trends have undermined the moral/therapeutic dichotomy during the
twentieth century, and yet have also made it difficult to see where we now
stand. On one hand, the therapeutic trend has medicalized moral problems by
approaching them in terms of health and therapy.
On the other, the unmasking trend reveals that
therapy itself embodies moral values, thereby debunking its pretension to
function as a morally neutral replacement for morality. Both trends are at
work, for example,
in the case of alcoholism. Alcoholism is a disease,
according to the dominant view in the therapeutic
community.
Citizens and law enforcement agencies, however,
continue to regard alcohol abuse as something for which individuals should be
held accountable. Furthermore, Alcoholics Anonymous, the most popular form
of alcoholism therapy, conjoins an insistence that alcoholism
is a disease with moral (and religious) values
about
accepting personal responsibility. In my view, alcoholism is typically both a
sickness and something which involves wrongdoing (Martin 1999a). It is a
sickness insofar as it constitutes impaired agency, and it is concerned with
wrongdoing insofar as it violates responsibilities to care for one's health and
to be accountable for one's drinking behaviour.
Responsibility does not vanish once alcoholism has
ravaged one's capacity directly to control drinking, for even then there
remains a duty on the alcoholic's part to seek and to cooperate with available therapeutic
help. Nevertheless, the different social constituencies dealing with alcoholics
have strikingly different emphases: therapists emphasize non-judgmental
helping, law enforcement personnel accentuate punishment for alcohol-related
crimes, insurance companies focus on alcoholism's cost liabilities, and
legislators formulate laws that provide incentives for responsible drinking behaviour.
All of these emphases overlap at various junctures, and
as a society, we need a comprehensive perspective
that renders them coherent.
Like alcohol dependency, depression generates
questions about responsibility. As a general point, recently
noted by Lawrence Becker, both mental and moral
health exclude the crippling forms of severe depression; they exclude any of
"the basic personality tenors (phobias, distrust, pessimism, depression)
that paralyze agency or render agents unable to feel or express empathy, or
unable to take a benevolent interest in others" (Becker 1998, 104). What I
said about depression impairing autonomy is germane to responsibility issues,
but my primary focus was elsewhere--on personal meaning and values.
Ghaemi rightly insists that severe pathological
depression "almost always interferes with the free, rational exercise of
moral agency due to cognitive distortions." Equally important, he insists
that severe depression
needs treatment, and that its value aspects should
not sanction avoiding help--a dangerous practice that results in part from the
cognitive and emotional distortions involved in severe depression, and in part
from the continuing social stigma of mental illness.
Ghaemi is also on target when he says that I failed
to distinguish between insights that occur during or after a
state of depression. Severe depression is perhaps
rarely a source of insights while it lasts, given the emotional and cognitive
inhibition it causes. Mill's insights came after, and in light of his
suffering, not during it.
Value judgments enter the discussion in another way.
Ghaemi outlines the "depressive realism" approach to understanding
depression, an approach that finds some correlation between a state of mild
depression and a realistic grasp of the world. I alluded to that literature
without emphasizing it. If anything, I discussed psychoanalytic perspectives
more extensively, while also taking account of biochemical and
cognitive-behavioral approaches.
My themes cut across the varied
psychological-psychiatric perspectives, and I did not intend to make a
"conceptual argument" for associating depression with insight,
especially if "insight" connotes accurate perception. Ghaemi cites his own and others ‘studies
suggesting that insight is correlated at most with the
milder forms of depression, and that finding is
consistent with my views.
Empirical studies tend to focus on how depression
affects one's knowledge of facts ("reality testing") and to neglect
value judgments and their connections with one's changes in identity and wider
perspectives on life. Value judgments can be studied empirically, but only as
to: (i) how depression shapes individuals' beliefs about values (rather than
whether the values themselves are valid); and (ii) the extent to which those
value beliefs are adaptive or socially effective, according to a given
standard.
Hence, empirical studies would help us better
understand when depression is beneficial ("adaptive") or harmful only
if we begin with value assumptions that have not themselves been proven
empirically. Moreover, depression-linked changes in a person's values and
identity need not be changes for the better, contrary to the impression my
essay may have created. Autonomy and authenticity do not always produce more
substantive moral behaviours.
Immoral
or Ill?
§
President
Bill Clinton’s escapade with Monica Lewinsky provoked its share of therapeutic
commentary,
usually with something less than
clinical detachment. Clinton’s enemies derided him as a sexually disordered,
pathological liar.More gently, cartoonist Jules Feiffer diagnosed him as
emotionally immature—a
developmental failure of arrested
adolescence. Jerome D. Levin, a psychiatrist specializing
in addictions, was initially outraged
at Clinton, but his moral indignation subsided when he discerned symptoms of
the ‘‘Clinton Syndrome’’—a sexual disorder
characterized by low self-esteem and excessive need for emotional reassurance,
caused by being raised in a dysfunctional family. ‘‘There is no
mystery why Bill Clinton would have gotten into a virtually suicidal
relationship with Monica Lewinsky.
His legacy as an adult child of an alcoholic
(ACOA) compelled him to fill the emptiness of his childhood and to repeat the
addictive pattern of both his biological and his adoptive parents; his
relationship with Lewinsky revived a longstanding behavioral pattern; she
fulfilled a complex nexus of unconscious
needs.’’When Hillary Clinton voiced similar ideas, however, she was attacked
for rationalizing her husband’s immorality. At least in the political arena, it
seems that Clinton was either sick or salacious, but not both.
§
Far
greater controversy surrounds homosexuality. Until 1973, the American
Psychiatric Association (APA) listed homosexuality as a mental disorder.
Then it changed its mind and affirmed homosexual orientations and activities as
normal sexual expression. The swift reversal occurred largely because of
protests by gay rights activists who rejected the APA position as homophobic,
provoking a vote among
its members to decide whether homosexuality is
a disorder—an unprecedented and precedent-setting approach to an allegedly
scientific matter. The event dramatically illustrates how moral values, along
with
scientific research, shape conceptions of mental health and mental disorders.
Conversely,
it illustrates how therapeutic outlooks can advance moral understanding by
challenging bigotry and overthrowing ignorance. Even the widespread adoption of
the medical-sounding term ‘‘homophobia,’’ to refer to irrational fear and
hatred of homosexuals, has advanced acceptance of gays and lesbians.
Parity of Reasoning Supports Autonomy
Promotion as a Goal of Treatment in Depression
I want now to use “ parity of reasoning ” to justify
autonomy promotion, through psychotherapy, as a legitimate goal of treatment in
depression. Parity of reasoning holds that if the structure of an argument is
such that
its conclusions are justified, and the structure of a
second argument is sufficiently similar in all relevant respects, the
conclusions of the second argument are also justified. 1 This principle is also
known as “consistency” and relates closely to the adage “ Treat like cases
alike. ”
The moral
force of parity of reasoning stems from the concern that ethical judgments
become meaningless if they are inconsistent across cases. For example, it makes
little sense to hold someone culpable for driving at excessive speed and then
to exonerate another on the basis of his or her superior steering ability. If
no morally relevant difference exists between cases, an ethical judgment that
holds for one applies also to the other.
Prowess at the wheel of an automobile falls short as
a moral discriminator, and thus the “ better driver ” is also subject to
speeding laws. I want to show now that autonomy promotion is a normatively
defensible treatment goal in a number of medical settings. I want further to
show that provision of CBT in depression is sufficiently similar to these examples
in relevant moral respects. I will then invoke parity of reasoning to conclude
a normative case exists to promote autonomy in depression through
psychotherapy.
Conclusion
Just as therapy has clear moral implications,
morality should become increasingly attuned to psychological understanding and
to therapeutic values of healing and personal growth. The primary juncture at
which that attunement occurs is moral psychology--psychology of the moral life,
and moral aspects of psychology--a field that is only recently emerging from
the shadow of debates about abstract ethical theories on right and wrong. Those
theories themselves stand to benefit from greater psychological realism and
nuanced integration with a compassionate
therapeutic vision in responding to human suffering.
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