In today’s metropolitan world, due to various reasons such as changing conditions from the past, increasing urbanization, individuals become lonely, stressful life events, low socioeconomic level, genetic transfer of depression history in the family, social support system of the individual, that is, insufficient relationships with spouses, relatives, close friends, getting married and divorced. Depression is the most common psychiatric disorder. Depression symptoms are grouped under three headings: mood, physical and cognitive.
1) Mood Symptoms: depressed mood, decreased interest in all activities (anhedonia), low self-esteem, feelings of worthlessness and guilt,
2) Bodily Symptoms: fatigue and loss of energy (lethargy), too much weight loss or too much weight gain, marked change in sleep pattern such as insomnia or sleeping too much, too slowing of movements (psycho-motor retardation) or increase in movements (psycho-motor agitation)
3) Cognitive Symptoms: It is a disorder that manifests itself with symptoms such as slowing of thoughts, decreased ability to concentrate and decision-making, and recurrent suicidal thoughts.
Although depression is a mood, it is different from affect. Mood is a longer experience and a state of emotion in which a person is in a particular situation for a period of time extensively and continuously. Affect is of shorter duration and can change during the day. In terms of duration and variability, mood can be compared to climate, and affect to weather. If the depressed mood lasts for 2 consecutive weeks and if the individual experiences at least 5 of the above-mentioned symptoms, major depression can be seen. If a depressed mood is clearly observed in the individual for at least 2 years, the diagnosis of ongoing depression disorder (dysthymia) is made.
Subtypes of Major Depressive Disorder
The DSM-V Diagnostic Criteria Handbook has defined 8 determinants of major depression: depressive, mixed, melancholy, atypical, psychotic, seasonally patterned, with catatonia, and time of birth (peripartum).
In the oppressive subtype, symptoms such as not being able to calm down at all, fear that something bad will happen, feeling overwhelmed or nervous are observed.
In the mixed subtype, high mood, increased self-esteem and grandiose thoughts, speaking more than usual, flight of thoughts, increased goal-directed activity at work, school, or sexually, an increased desire to perform activities that may have adverse consequences (eg. excessive spending or increased sexual activity), decreased sleep.
In the subtype showing melancholy features, anhedonia and feeling unwell, unresponsiveness to stimuli can be seen. In addition, a deep depression, depressed mood, emotional emptiness, waking up early in the morning and feeling worse in the morning, loss of appetite, weight loss, intense feelings of guilt, psychomotor agitation or psychomotor retardation can be seen.
In the subtype showing atypical features, reactivity, i.e. reacting to events that are thought to be positive or positive, mood opening and improvement are observed. In addition, a significant increase in weight gain and desire to eat, sleeping too much (hypersomnia), heavy arms and legs, feeling like lead (lead paralysis) and hypersensitivity to interpersonal rejection are seen.
In the subtype showing psychotic features, the individual experiences delusions and hallucinations. Psychotic symptoms are generally compatible with the individual’s mood, but psychotic symptoms that are not compatible with mood can also be seen. While depression issues such as guilt, inadequacy, death and deserving punishment are included in the content of all delusions and hallucinations in mood-consistent psychosis symptoms, none of these are observed in mood-inconsistent psychosis symptoms. In this subtype, more intense psychomotor agitation or retardation can be seen.
Persons in the seasonally patterned subtype experience depression in two consecutive winter seasons, and the depression disappears in the spring. It occurs when the onset of major depression regularly coincides with certain times of the year. This cycle is observed consistently in at least 2 years. It manifests itself with symptoms of excessive sleeping and eating, carbohydrate-heavy diet, weight gain, fatigue and exhaustion.
In the subtype with catatonia, speaking very slowly, being unable to move, being stricken like a cat by the neck, extreme negativism, resistance to all movement efforts and instructions, and stereotypical repetitive behaviors can be seen.
In the birth-onset subtype, if the symptoms of major depression occur during pregnancy or within 4 weeks after birth, this period is called post-partum depression.
Neurobiology of Depression
The first research on depression is thought to date back to the Hippocratic period. Hippocrates made studies on the brain, thinking that mental disorders are the biological infrastructure. He suggested that mental disorders were caused by 4 fluids, namely blood, black bile, yellow bile and phlegm, and attributed the cause of depression in the person to the change in body fluid secreted from black bile. He suggested in his studies that the excess fluid secreted from black bile would lead people to melancholy (Karamustafalıoğlu and Yumrukçal, 2011).
Studies conducted today show that low activation of noradrenaline, dopamine and serotonin hormones is effective in the appearance of depression disorder. Changes in noradrenergic transmission lead to reluctance, slowing, and distraction; changes in dopaminergic transmission to feelings of malaise, worthlessness and guilt, hallucinations; The change in serotonergic transmission causes anhedonia, dysphoria, anxiety, anorexia, insomnia, decreased libido and suicidal thoughts.
There is an increase in the level of cortisol, known as the stress hormone, in the neuroendocrine system. The HHA axis (hypothalamus-pituitary-adrenal axis), ie the brain system that manages stress, may be overactive during major depression. As I have mentioned below, increased amygdala activation in individuals experiencing depression triggers the release of cortisol from the HHA axis into the body by sending a signal to activate the HHA axis (Kring, Davison, Neale, and Johnson, 2007).
Problems in the thyroid gland and irregularity in the secretion of growth hormones play a role in depression.
In brain imaging studies, some changes have been detected in the brains of individuals with depression compared to individuals without depression. Individuals experiencing depression have increased amygdala activation. In a study of individuals with and without depression, when both groups were shown a picture of happy and unhappy facial expressions in a community, individuals with depression noticed unhappy faces more quickly than those without depression. Other brain regions where changes are observed are the hippocampus and the dorsolateral prefrontal cortex. When individuals with depression are exposed to emotional stimuli and their emotions are requested to be regulated, decreased activity is observed in these regions (Fales, Barch, Rundle et al., 2005).
Psychological Factors Effective in Depression
There is a triple cognitive mechanism in each individual’s mind. In the center are our schemas, that is, our basic beliefs, our intermediate beliefs/rules that develop depending on the schemas, and our automatic thoughts that are passing through our minds at every moment. How we make sense of the world is about how we use our triple mechanism. Beck (1979) grouped schemas/core beliefs under three headings: helplessness, dislike, and evil. The basic belief category that is active in the depressed individual is ‘not being liked’. In other words, the individual basically characterizes himself with thoughts such as ‘I am inadequate’, ‘I am not wanted’, ‘I am not loved’, ‘I am alone’. Beck (1967) advocates the negative triad theory. The depressed person has a negative view of the self, the world and the future. Another model Beck put forward about depression is the ABC model. In this model:
A) a triggering adverse event
B) The person’s interpretation of the event
C) It constitutes the emotional and behavioral outputs of the event.
When a depressed person experiences an event A (eg, having failed the exam), he will interpret the event as ‘I am already a failure and I deserved it’ in part B, and its reflection in part C will show itself with symptoms such as introversion and depressed mood.
Individuals with depressive disorder have an intense cognitive distortion compared to individuals who do not. Beck (1995) identified these cognitive distortions:
1) Arbitrary Inference/Jumping to Conclusion: One’s direct conclusion without sufficient evidence.
2) Selective Abstraction/Mental Filtering: Focusing on a single detail of events, not conceptualizing the event from a single detail.
3) Overgeneralization: Generalizing a single event and perceiving general negative events.
4) Magnification and Minimization: Enlarging the negative events and reducing the positive ones.
5) All or Nothing Thinking: It is the interpretation of an event as either happened or not. It is black and white tip. People with this way of thinking do not see grays in the black and white spectrum.
6)Personalization: Attributing a negative event to oneself and thinking that it is related to oneself.
7) Catastrophizing: Always seeing the future negatively.
8) Should/must Thinking: The person sets excessive rules for himself and exaggerates the bad results if these rules are not fulfilled.
9 Mind Reading: Assuming you know what people are thinking without adequate knowledge of what they are thinking.
10) Reaching Conclusion from Emotion: Despite the contrary evidence, the person believes that what he feels is true by denying the evidence.
11) Labeling: Attributing general negative characteristics to oneself or others.
Another theory put forward in the formation of depression is Susan Nolen-Hoeksema (1991)’s Rumination Theory. According to the theory, it is suggested that the individual’s repetitive pondering on the same distressing events and thoughts triggers depression more.
Can depression be treated? Although there are various treatment methods for depression, if the person has mild depression symptoms, psychotherapy, if the person has moderate depression, psychotherapy and medical treatment, if severe, hospitalization or medical treatment can be applied.
Cognitive Behavioral Therapy (CBT), the effectiveness of which is supported by research, is applied in today’s psychotherapy practices. The main purpose of CBT is to replace the negative thoughts about himself in the mind of the person with depression symptoms with more rational thoughts. At this stage, the therapist allows the individual to evaluate the validity of existing beliefs and to arrive at new conclusions that are realistic, meaningful and useful for him or her by repeatedly asking questions about the thoughts that the person believes to be certain.
With the B part of the ABC model put forward by Beck, the part of how the person interprets and evaluates the events is changed. This change can be compared to someone who looks at the world with dirty glasses, cleaning the glasses over time and seeing the world more clearly. In psychotherapy, it is possible to change the emotion and then the behavior patterns of the person by changing the evaluation and meaning, that is, the cognition part. The aim of CBT is to change the distorted beliefs of the depressed individual about the self, the world and the future.
In order to activate behavioral activation, the individual with depression is constantly supported with homework and it is ensured that he takes responsibility. By following a method in this way, it is ensured that the individual is always active, not passive, in psychotherapy.
The most important resource in the treatment of depression is the patient’s internal and external resources. While the psychotherapy process continues, the internal and external resources of the person are of great importance in the treatment. Internal resources constitute the coping mechanisms that people develop in the face of problems. Discovering and strengthening these coping mechanisms in individuals with depression will enable them to progress more quickly in therapy. External resources are our social support systems. Factors such as spouse, family, lover, close friend, relative constitute our external resources. The fact that the depressed person receives support from external sources while the therapy process continues, serves as a protective function.