Depression
What is depression? Depression has a variety of symptoms, such as loss of energy, loss of interest in activities and in life, sadness, loss of appetite and weight, difficulty concentrating, self-criticism, feelings of hopelessness, physical complaints, withdrawal from other people, irritability, difficulty making decisions, and suicidal thinking. Most depressed people feel anxious as well. They often feel worried, nauseated, dizzy, and sometimes have hot and cold flashes, blurred vision, racing heartbeat, and sweating.

Clinical depression is not the same as grieving after the loss of a loved one through death, separation or divorce. Feelings of sadness, emptiness, low energy and lack of interest are normal during grief. Anger and anxiety can also be part of the normal grief process.

Clinical depression differs from normal grief in that clinical depression sometimes may occur without a significant loss. Moreover, depression may last longer than grief and includes feelings of self-criticism, hopelessness and despair.

It would be an unusual person who said that he never felt "depressed." Mood fluctuations are normal and help inform us that something is missing in our lives and that we should consider changing things. But clinical depression is much worse than simple fluctuations in mood. Clinical depression varies from mild to severe. For example, some people complain of a few symptoms which occur some of the time. Other people, suffering from a severe depression, may complain of a large number of symptoms, which are frequent, long-lasting and quite disturbing. Because there are various degrees of depression, the severely depressed patient may wish to consider a number of treatments in combination.

Who Gets Depressed?
Depression is not something that happens to people who are "unusual" or "crazy." It is everywhere. Along with anxiety (which occurs more frequently than depression), it is the common cold of emotional problems. During any given year a large number of people will suffer from a major depression. 25% of women and 12% of men will suffer a major depressive episode during their lifetime. The chances of reoccurrence of another episode after the initial episode are high.

The reason for the sex difference in prevalence of depression is not entirely clear. Possible reasons may be that women are more willing to acknowledge feelings of sadness and self-criticism, females are undermined from an early age by being taught to be helpless and dependent, women control fewer sources of rewards than men do, and their achievement is often discounted. Another factor may be that men "mask" or hide their depression behind other problems, such as alcohol and drug abuse.

What Are The Causes Of Depression?
There is no "one" cause of depression. We view depression as "multi-determined" - that is, it has biochemical, behavioral and cognitive components. We will examine each one.

1. Loss of Rewards. Have you experienced significant losses in your life recently - for example, loss of work, friendships, intimacy? The behavioral model of depression emphasizes the importance of reinforcement in the onset and maintenance of depression. There is considerable research evidence that people who suffer significant life stresses are more likely to become depressed - especially, if they lack or do not use appropriate coping skills.
2. Decrease of Rewarding Behavior. Are you engaged in fewer activities which were rewarding in the past? Depression is characterized by inactivity and withdrawal. For example, depressed people report spending a lot of time in passive and unrewarding behavior - such as watching television, lying in bed, brooding over problems and complaining to friends. They spend less time engaged in challenging and rewarding behavior, such as positive social interactions, exercise, recreation, learning, and productive work.
3. Skill Deficits. Are there social skills or problem - solving skills which you lack? Depressed people may have difficulty asserting themselves, maintaining friendships, or solving problems with their spouses, friends, or work colleagues. Because they either lack these skills or do not use the skills they have, they have greater interpersonal conflict and fewer opportunities to make rewarding things happen for them.
4. New Demands.: Are there new demands for which you feel ill-prepared? Moving to a new city, starting a new job, becoming a parent, or ending a relationship and trying to find new friends can be sources of significant stress for many people.
5. Lack of self-reward. Many depressed people fail to reinforce themselves for positive behavior. For example, they seldom praise themselves or they are hesitant to spend money on themselves. Many times depressed people think that they are so unworthy that they should never praise themselves. Some depressed people think that if they praise themselves that they will become lazy and settle for less.
6. Exposure to helplessness.: Depression may result from continuing to stay in a situation in which you cannot control rewards and punishments. The individual may feel sad, tired, loss of interest, and hopeless because he believes that no matter what he does he cannot make things better. Examples of helplessness are unrewarding jobs or dead-end relationships.
7. Exposure to continual punishment. This is a special kind of helplessness - not only are you unable to get rewards, but you find yourself criticized by others and rejected. For example, many depressed people may spend time with people who criticize them or hurt them in various ways.

Although each of the above factors may make you prone to depression, they do not necessarily have to result in depression. One may experience a loss in life but reverse the loss by increasing rewarding behaviors, learning new skills, redirecting attention and energy into new goals, and asserting yourself. You are also more likely to become depressed if you think that you are entirely to blame, that nothing can change and that you should be perfect at everything. These interpretations of stress and loss are the "cognitions" or thoughts that you have about yourself and your environment. Cognitive therapy is specifically focused at identifying, testing, challenging and changing these excessively negative views of life.

How Does Thinking Affect Depression?
There are other causes of depression that have to do with the way you think ( your "cognitions"). Some of these causes of depression are described below:

1. Unrealistic expectations. Many depressed people have unrealistically high standards for themselves and for other people. They believe that they (or others) shouldn't make mistakes, their job should be free of conflict or should be fun all the time, or that their marriage should be completely happy. Another group of depressed people have unrealistically low standards - they continually accept less than they could probably get elsewhere.
2. Automatic thoughts. These are thoughts that come spontaneously, seem plausible, and are associated with negative feelings like sadness, anxiety, anger and hopelessness. Examples of these distortions in thinking are the following:
* Mind reading "He thinks I'm a loser"
* Labeling "I'm a failure. He's a jerk."
* Fortune telling "I'll get rejected. I'll make a fool of myself."
* Catastrophizing "It's awful if I get rejected. I can't stand being anxious."
* All or nothing "I fail at everything. I don't enjoy anything. Nothing works out for me."
* Discounting positives "That doesn't count because anyone could do that."
3. Maladaptive assumptions. These are the rules or philosophies of depressed people. They include ideas about what you think you should be doing or your theories about life:
* "I should get the approval of everyone."
* "If someone doesn't like me, that means I'm unlovable."
* "I can never be happy doing things on my own."
* "If I fail at something, then I'm a failure."
* "I should criticize myself for my failures."
* "If I've had a problem for a long time, then I can't change."
* "I shouldn't be depressed."
4. Negative self-concept. People who are depressed often focus on their short-comings, exaggerate them, and minimize any positive qualities they may have. They may see themselves as unlovable, ugly, stupid, weak, or even evil.

What Is Cognitive-behavioral Treatment?
The cognitive-behavioral treatment of depression is a highly structured, practical, and effective intervention for patients suffering from depression. In cognitive-behavioral therapy the therapist initially attempts to focus on current symptoms and current thoughts and behaviors. The therapist and patient evaluate the specific level of depressive and anxiety symptoms using standardized, valid self-report forms such as the Beck Depression Inventory, the Symptom Check-List, or the Locke-Wallace Marital Adjustment Scale. The effectiveness of the therapy may be monitored by referring to these initial measures of symptoms and other goals which the patient establishes with the therapist. For example, the patient is asked in the initial meetings to specify a number of goals he wishes to attain - such as, increasing self-esteem, improving communication, reducing shyness, or decreasing haplessness and loneliness.

How Effective Is Cognitive-behavior Therapy for Depression?
Numerous outcome studies conducted at major universities throughout the world have consistently demonstrated that cognitive therapy is as effective as anti-depressant medication in the treatment of major depression. Within 20 sessions of individual therapy, approximately 75% of patients experience a significant decrease in their symptoms. The combination of cognitive therapy with medication, in some studies, increases the efficacy to 85%. Moreover, most patients in cognitive therapy maintain their improved mood on follow-up two years later. This advantage of "maintaining gains" is due to the fact that in cognitive therapy the patient should not only reduce his symptoms, but he should learn to understand the distortions in thinking and behavior which are associated with the depression and learn self-help rather than dependence.

Are Medications Useful?
There are a variety of medications that are quite effective in the treatment of depression. These include prozac, paxil, zoloft, effexor, tofranil, wellbutrin, elavil, nardil, parnate, lithium, and several other medications. It takes two to four weeks for you to build up a therapeutic level. Some medications may have negative side effects and some of these side effects may decrease over time or they may be handled with combinations of other medications. In some cases, patients with severe depression may wish to consult their physician about the possibility of electro convulsive treatment (ECT).

What We Expect from You as a Patient
Cognitive-behavioral treatment of depression requires your active participation. During the initial phase of therapy your therapist may request that you come to therapy twice per week until your depression has decreased. You will be asked to fill out forms evaluating your depression, anxiety and other problems, and to read materials specifically addressing the treatment of depression. In addition, your therapist may ask you to fill out forms weekly that evaluate your depression and other problems that are the focus of therapy. Your therapist may give you homework exercises to assist you in modifying your behavior, your thoughts, and your relationships. Although many patients suffering from depression feel hopeless about improvement, there is an excellent chance that your depression may be substantially reduced with effective treatment.

Some data on this page was derived and/or influenced by the writings of Robert L. Leahy B.A., M.S., Ph.D., Director of the American Institute for Cognitive Therapy