DEPRESSION

DEPRESSION

The words ‘depression’ or ‘depressed’ are often used by the public (and clients)

to indicate a passing feeling or mood of sadness, lethargy, guilt, grief, or a low mood.

In common usage, they are synonyms for feeling flat, down, or ‘having the blues’. The

word depression, originating in Latin, literally means “to press down” (Reevy et al.,

2010, p. 192). Depression is also used as a clinical term to suggest a particular type

of mental disorder category, as described in the ICD-11 (World Health Organization,

2022), or DSM-5-TR (American Psychiatric Association [APA], 2022). The variation

degrees under the diagnostic threshold.

Depression is characterised by periods of low mood or sadness and/or a loss

of pleasure or interest in previously enjoyed activities (APA, 2022). While it can lead

to significant stress and impairment in life, it is most commonly a response to various

difficulties or stressful life experiences that most people are likely to encounter at some

stage in life (Reevy et al., 2010). These features were described as far back as

Hippocrates (Radden, 2003) as being part of melancholia, and while other disorders

have come and gone, descriptions of depression remain consistent throughout the

modern diagnostic editions (Frances, 2013). Indicators of depression typically include

low mood, low interest in activities, or low ability to experience pleasure, weight

and increased concern with physical complaints (APA, 2000, 2013, 2022).

DISTINGUISHING BETWEEN DEPRESSION AND GRIEF

Historically, mental health practitioners and researchers have had difficulty

distinguishing between grief or bereavement, and clinical depression as per the criteria

of the DSM (Cacciatore & Theilman, 2014). Like depression, grief can negatively

impact functioning, have marked increases in negative emotions including sadness

and guilt, sleep disturbances, lack of ability to experience pleasure, and may involve

thoughts about death (Hall, 2013). Although they overlap in features and client

experience, grief is understood as a natural adjustment response to loss, while major

depressive disorder is viewed as a pathological syndrome. Grief and depression

of complicated grief that may have depression as a symptom. These grief reactions

occur most of the day, nearly every day for at least a month. The individual experiences

clinically significant distress or impairment in social, occupational, or other important

areas of functioning (APA, 2022). Interpersonal Psychotherapy, an approach

discussed later in this chapter, provides a simple formulation and way forward with

complicated grief, by considering one’s indicators of depression being ‘caused’ by

unresolved grief, and that interventions that target this will help to relieve the person’s

depression (Weissman et al., 2018).

DEPRESSION AND SUICIDE

suicide is 2%. The public lifetime risk is .5% (Bostwick & Pankratz, 2000). This would

suggest that clients with depression are between four to eight times more likely to

suicide in their lifetime than non-depressed individuals. Suicide risk assessment and

prevention should be prioritised with depressed clients given their elevated risks.

DEPRESSION AND VARIOUS POPULATIONS

As a rule, rates of depression are higher for women than men (Chentsova-

Dutton & Tsai, 2009). In Australia, 5.3% of men had symptoms of an affective disorder

in a twelve-month period compared to 7.1% of females (ABS, 2008). This difference

increases in more traditional gender role societies, however when the rates are closer,

research has not yet clarified whether this is due to decreased depression in females

Australia, from the ages between 4-17, reporting symptoms in a 12-month period

(Lawrence et al., 2015). The symptoms are generally the same as adult depression,

however more likely to be displayed as irritability or flat affect than a depressed mood,

and their moods are more variable due to their ability to be influenced by what is

happening around them (Stark et al., 2006). Children and adolescents may also

display anger, guilt, and misery. They may withdraw from others, be difficult to soothe,

and find it hard to be motivated, such as finding the energy to do homework.

Additionally, they may display low self-esteem, and become suicidal (Huberty, 2012).

Indigenous Australians typically have higher rates of psychological distress (i.e.,

depression and anxiety), in contrast to non-Indigenous counterparts (Jorm et al.,

anxiety than do labour migrants (Lindert et al., 2009). This increased incidence may

be associated with higher rates of trauma from their country of origin.

It should be noted that depression is understood or spoken about differently in some

other cultures. For example, several cultures report depression using physical rather

than psychological language, such as focusing on changes in appetite, sleep, or the

presence of headaches. Western clients tend to report their depressive psychological

symptoms more so than referring to the physical symptoms (Chentsova-Dutton & Tsai,

2009). Some intercultural clients may refer to depressive symptoms as ‘problems of

the heart’, nerves, or fatigue (Nezu et al., 2009).

MULTIFACED NATURE OF DEPRESSION

personality, chronic pain and/or illness, some medical conditions and hormone

changes, and some medications (APA, 2013; Berman, 2009; Goodman & Brand,

2009; Hammen, 2009; Hopko & Robertson, 2008; Johnson, 2009; Mustata & Gregory,

2009; Reevy et al., 2010; Sachdeva et al., 2009; Schwartz, 2009; Schwartz & Tripp,

2009). Additionally, while depression can be understood as a disorder in its own right,

it can also be viewed as a symptom of other conditions, physical, chemical, and

psychological (Gautam et al., 2017).

Depression’s many potential pathways contribute in varying degrees to each

presentation (Fang & Mao, 2019; Roose et al., 2013). It is important that counsellors

are mindful potential contributors when doing assessments. Counsellors might refer

develops the treatment focus with the client, monitors treatment response, and adjusts

as needed. An alternative is to address more than one area at a time, either as the

sole intervention provider or as part of an intervention team where resources are

available.

Depression is predominantly recognised and treated as a primary mental

disorder within Western mental health systems, and is often treated with medication.

Frances (2013), the former Chair of the DSM-IV Task Force, critiqued the diagnostic

criteria for depression and how this has been used. He highlighted that while a

diagnosis of major depressive disorder (MDD) is quite beneficial at helping people with

severe depression gain access to treatment; it also readily captures people with

normal emotional experiences (e.g., mild depression) and ignores the contextual role

solutions for addressing mental health challenges are medications” (p. 5-7). The report

goes on further to say that “the crisis in mental health should be managed not as a

crisis of individual conditions but as a crisis of social obstacles which hinders individual

rights” (p.19). The DSM5-TR (APA, 2022) and ICD11 (WHO, 2022) have provided a

common language and descriptions that enable classification of mental health issues

including depression. This classification greatly assists in research, diagnosis,

demarcating eligibility for services; and assists practitioners to varying degrees with

case conceptualisation and treatment planning. An unfortunate by-product can be a

form of medical reductionism that predominantly locates the pathology in the individual

and decontextualises the symptoms.

alternative approaches, including those that address lifestyle factors associated with

depressive symptoms.

1. MEDICATION

The most widely known medical treatment for depression is anti-

depressants prescribed by general practitioners and psychiatrists. They are

commonly the first treatment offered in medical contexts and may also be offered

in combination with therapy. In terms of effectiveness with depression, medication

is generally as effective as counselling, while it outperforms counselling with more

prolonged or severe depression (Imel et al., 2008). Antidepressants have come

under criticism as researchers are recognising that typically only research that

shows positive large effects are published, thus giving inflated average effect size

(McKay et al., 2006). In other words, depending on which doctor the client is seeing

will determine how effective their anti-depressant medication is. In the study just

cited, the psychiatrist with the best results had better results with their placebo pill

than 80% of the doctors who prescribed the active medication.

2. COUNSELLING FOR DEPRESSION

Counselling for depression is generally effective at reducing symptoms and

improving life quality (Cuijpers et al., 2008; Hoyer et al., 2006; Lambert, 2013).

While the debate over which specific therapy is most effective for depression

continues, meta-analyses demonstrate that no bona fide therapy has been proven

(Leuzinger‐Bohleber, 2015). Freud believed depression was an alternative

manner of mourning the loss of a significant other. Rather than a progressive

resolution to the loss of a loved one as most do in grief, the person gets stuck

in ambivalence and inner conflict towards the object of loss, may lose

awareness that they are mourning, and punishes a part of their ego (Mustata &

Gregory, 2009; Taylor, 2008, 2015). This is where we get the saying that

depression is anger turned inwards (Rehm, 2010). The aim of treatment is to

help raise the awareness and insight of clients into their range of unconscious

internal reactions and processes towards the loss and help them process their

grief. Psychodynamic approaches comprise the more recent developments in

the psychoanalytic word, to help clients to address specific internal or

interpersonal conflicts. These psychodynamic psychotherapy approaches use

increase self-awareness, and the resolution of conflicts in the client’s life.

B. Behavioural model

According to behaviourists, people choose behaviours to help them gain

rewards and/or avoid distress. In this model, the assumption is that depressed

people fail to receive sufficient positive incentives for healthy behaviours and

will tend to withdraw from certain other behaviours and activities to avoid short

term unpleasant events. Avoidance can additionally be problematic because

avoiding potential for distress may also mean they fail to place themselves into

situations whereby they gain longer term benefit (Spiegler & Guevremont,

2010). The aim of the interventions is to help clients stop practising behaviours

al., 2001).

Intervention consists of having clients identify the various situations they

avoid and the behaviours that are reinforced through such avoidance,

identifying life goals, and then identifying strategies to engage in positive

behaviours that are likely to be reinforced and lead to the clients’ longer-term

goals (Spiegler & Guevremont, 2010). For instance, job seekers can become

demoralised and depressed when their efforts at finding work continue to be

unsuccessful. They may engage in behaviours that avoid the short-term risk of

rejection, but in doing so, may find themselves less likely to achieve the longer-

term satisfaction accompanied by securing employment. The behavioural

counsellor, using the strategy of behavioural activation, might help them

develop a stronger awareness of the longer-term goals, activities to help them

behaviour therapy (founded by Albert Ellis) are the two main schools of

cognitive behaviour therapy approaches. Aaron Beck proposed that faulty

cognition with a bias towards negativity causes and maintains depression.

Cognitive therapy argues that it is not so much what happens to a person that

makes them depressed, but that people feel depressed as a result of tending

to engage in patterns of thinking and beliefs about the events, themselves, and

the world generally, with a negative bias (Blackburn et al., 2006). While one

person may experience failing in an exam as disappointing but nonetheless a

prompt to study harder, a depressed person might view it as evidence that they

are never going to succeed, that they might as well give up, and that they are

treatment may involve helping clients learn to recognise the difference between

functional and dysfunctional thoughts, helping them monitor their thoughts, and

learn to replace their dysfunctional thinking and beliefs with more adaptive

alternatives. The behavioural aspects of this approach are drawn from

behaviourist theory, and use techniques such as exposure, activity scheduling,

and behaviour modification. Relaxation training is also prescribed. Skills

training, like assertiveness, or stress management, are also key components

of this approach. An important initial step when intervening with depression is

pleasant activity scheduling (also referred to as behavioural activation). This

involves helping the client to identify pleasant activities, and those that also

provide challenge, and then setting goals together to increase these by creating

a weekly schedule comprising these activities. Although this seems like a very

Mindfulness-based cognitive therapy (MBCT) is a newer approach,

derived from CBT, which emphasises mindfulness-based meditation as a core

treatment for depression, and has shown promising signs especially for treating

recurrent depression (Kahl et al., 2012). It focusses on interrupting ruminative

patterns of thinking which are often associated with depressive relapse. The

main difference between traditional CBT and MBCT is that the latter focuses

more on changing one’s relationship with their thoughts, by noticing and

observing inner dialogues, rather than challenging or changing thinking

patterns through cognitive restructuring. Clients are helped to see themselves

as ‘having’ thoughts, or experiencing difficult emotions, rather than believing

efficacious approaches in CBT, its primary difference is in the way that it

approaches thoughts, feelings, and behaviours. ACT sees the context and

function of private experiences as the primary target of intervention, helping a