Conclusions

In this last chapter I will try to bring out some of the main themes we have been following. Our first task is draw distinctions between vulnerability, onset, maintenance, and recovery, relapse, protection/resistance. As we have progressed through this book the reader will have become aware that these aspects share complex relations. Below is but a brief summary.

Vulnerability

Genes: For some the greatest vulnerability is, in the main, genetic. But this percentage is likely to be small. Also it is extremely unlikely that there is a gene or genes for depression. The genetic contribution will probably arise from ranking, ingroup–outgroup algorithms (or possibly attachment), i.e., the gene(s) will have some role in the social domain and relate to social functioning rather than depression as a mood state per se. Depression is a human construct of the dysfunction. A key question is threshold (McGuffin et al., 1991).

Personality: Some personalities seem more at risk than others. Again genes may play some role here but these may be different from those of depression where there is not a personality aspect. To put this more crudely, genes for introversion, which may convey risk, may be different from genes for bipolar depression. More important is that personality can also be affected by perinatal factors and of course by development factors.

Development: We now know that early life not only influences psychological processes but also influences the way the nervous system matures. Animal work suggests that very early distortion in development may be difficult to compensate. Personality represents the combined effect of experience interacting with biological endowment. A vulnerability may be biologically altered via early life or wired in, when none may have existed had the person had a different early experience. In any event the notion of latent self–other internal representations and the experience of an affectionless childhood, and over-control in early life seem involved. But not all those who experience an affectionless early life will come to suffer depression.

Compensation: A child who has a rough time early in life may find some goal or ability that allows some compensation to developing a depression. For example, a person was poorly treated early in life but had a talent for music. His commitment and the appreciation of his talent by others seemed to protect him. How far/long this compensation would work no-one knows. But the point is that there may be things within a person – or relationships or opportunities – that compensate for a potential vulnerability (see also pp.272–273).

Social factors: Lack of close relations may set the psychobiological environment for the activation of depression as suggested by Brown (see Chapter 15). Included here might be poor marriages that do not function as supporting selfobjects or have chipped away at self-esteem; also entrapments. More positively, social factors may protect against depression even in the face of some underlying biological or personality, vulnerability factors.

Onset

Genes: There are cases where onset is related to some underlying genetic aspect that determines the time of the first and subsequent episode. Those depressions that seem to have regular cycles may be a case in point. The relationship of life events to timing is unknown, but recent evidence suggests a connection.

Biological: Many biological changes can produce an onset. Head injury, hormonal change, the menopause, thyroid dysfunction, steroid and other substance abuses, various physical (viral) illnesses, and so forth. Their interaction with social and psychological factors is still to be researched.

Season: There is now growing evidence that some depressions are light triggered.

Life events: There seem to be various life events that can cause depression for most people, e.g., loss of a child, and those that have long-term implication for roles and plans as discussed by Brown and his colleagues (see Chapter 15). In some cases the coping style may be compromised because the event itself (loss of a confidant) removes the main source of coping. Brown’s work suggests that a majority of depressions are associated with life events. Abuse and entrapments and family pressures also play a role.

A Combination: Interactions between personality, incentive structure, coping or cognitive style, self-esteem, latent memories, and life events are probably involved at the point of onset. Events that have particular meaning to a person’s sense of self, or selfobject relationships which no longer function, and a reduced sense of self-efficacy come together to produce onset. In our view a change in how a person feels valued by self and others is a crucial variable. Hopelessness may be another.

Spirals: Various factors in biopsychosocial functioning may act in a recursive feedback pattern to produce a spiral downwards into depression.

Maintenance

Biological: Once a person has entered a severe state of depression their biology may be so disturbed that the depression remains until a biological shift takes place. Whether genes play a role in maintenance as opposed to onset is unknown. Is it possible to get depressed because of a life event (and one would not have become depressed without this life event) and then be trapped in it because of a genetic inflexibility in some way? Are those genes controlling onset or personality different from genes controlling maintenance? We don’t know. Inappropriate medications or other substances with depressogenic side effects should also be considered.

Cognitions: There is some general agreement that, if not involved in cause, then cognitions are almost certainly involved in the maintenance of many depressions. The automatic thoughts outlined by Beck et al. (1979) act as positive, recursive feedback systems to maintaining depressive self-organisational patterns. Also, Teasdale (1988) has suggested that we can be depressed about being depressed. Shame about depression is also common. Entrapments at an internal level (e.g., guilt or having to ‘achieve’) may block changes in life style.

Unresolved issues: A person may have functioned well until a certain point and then get depressed. Once depressed, a number of latent self-organisational patterns (e.g., of not being loved as a child, loss of a parent, abuse) may re-emerge. In this sense the person begins to live through the depressive experiences that had been blocked off in some way earlier in life (e.g., Gut, 1989). Until the issues, arising from earlier in life, are resolved the depression remains. This is much more common than is currently recognised. Another way to think of this is as a breakdown in compensation mechanisms (see pp.272-273).

Events: A person may get depressed for any number of reasons. As a result of the depression they may lose their spouse or job, or the marriage may turn sour. These subsequent events and losses also act as recursive feedback and maintain the depression. Lack of opportunities to change one’s life style may also be involved (entrapments).

Interpersonal: Various (often family) interpersonal factors such as poor reconciling behaviours, increased hostility, abuse, and so forth may lead to a cycle of put-down and the undermining of a person’s sense of value and efficacy. Depression-maintaining feedback can be elicited from the environment.

Social skills: Aperson may become depressed because of the death of a spouse. However, their introverted personality or low social skills may make it difficult to find other supporting relationships. In other cases the low rate of emission of positively rewarding behaviour can act to maintain low levels of behaviour and depression.

Recovery

Biological: In the presence of some specific biological disturbance (e.g., thyroid, hormonal) much depends on the skill of the psychiatrist in diagnosis, and the preparedness of the psychiatrist to explore possibilities. In other cases directly changing brain state may be helpful with drugs or ECT, light therapy for SAD. Diet and exercise can also be helpful in some cases, as might sleep deprivation, though these are controversial.

Drugs: Why does a drug work for one person and not another? There are various psychological reasons, since drugs do not re-train or reeducate and do not address any of the social problems or previous historical problems a person may have. But a biological reason can be in the different ways individuals metabolise drugs. The same dose may not result in equal amounts getting to the brain in different individuals. Also of course non-compliance can be a problem. Some patients do better with MAOI’s rather that tricyclics (e.g., Stewart et al., 1989).

Psychological: Much depends on the person’s ability to work psychologically and the skill of the therapist. Those who dogmatically follow only one approach are likely to have failures. At the very least therapists should be skilled in basic counselling techniques. Nevertheless, it is important to identify positive feedback, such as: “When I’m depressed I can’t do anything, if I can’t do anything I’m a failure, as a failure I feel more depressed”, etc. Psychological interventions come to the rescue of the self and attempt to reduce internal self-downing, shame, and guilt, and increase explorative behaviour. New themes in life style may be necessary and new self-organisations may need to evolve.

Life events: Some depressions remit in the presence of life events. A set of events labelled “fresh start events” by Brown et al. (1988) are associated with recovery.

Social support: Many patients attest to the importance of having supporting, loving relationships whilst going through their depression and feel these played a large role in their recovery. Current evidence suggests that, for some at least, social/emotional support is crucial in the recovery process. Social support is a complex variable with different aspects however. In a few cases, some can feel smothered by too much support, or the marriage is the source of the problem. So the therapist should be cautious if and how family members are brought into therapy.

Spontaneous remission: There is an old saying, “It’s nice to be in the vicinity of a spontaneous remission”. This is a controversial area: some argue that there must be some reason (life event or change in relationships, etc.) that brought recovery; on the other hand, for some cases, spontaneous remission does seem to occur and we remain perplexed by it. However, over the decade research has suggested that often spontaneous remission is not spontaneous and the label owes much to lack of awareness on the clinician’s part.

Personal resources: Some patients have enormous resources for recovery (or what is called ego strength) and recover without professional help. Probably the vast majority of depressed people get themselves out of it by talking to friends or working through it or they experience fresh-start events. Certainly only a minority of depressed people come for treatment. Some radical theorists have even suggested that therapy of any kind is counter-productive. At the same time we should recognise that some depressions (up to 20%) may be chronic and drag on for years to such an extent that the person comes to think “This is just the way I am”. These will have serious effects on family life.

Relapse

Biological: One cause of relapse may be feeling better and stopping medication. Most believe that a period of six to nine months on medication is necessary, post-episode, in the majority but not all cases. In other cases failure to spot a cyclical depression and use lithium may increase the chance of relapse. The problem of relapse following withdrawal of medication may suggest that drugs (in some cases) actually produce artificial or unstable recovery as depicted by catastrophe theory (Gilbert, 1984).

Flight into health: In some cases patients make a flight into health that rarely lasts and therapists should be aware of this. Hence there is a premature termination of treatment. Careful follow-up is advisable. Cognitive therapists are now trying to identify those who recover but remain vulnerable. Providing small stresses and seeing if the negative cognitive style re-emerges is one paradigm. However, how long patients should be in therapy is controversial. The distinction between relapse and new episode is also controversial as researchers follow different criteria (e.g., BDI of less that 9 may not be an adequate measure of full recovery).

Failure to resolve: Some depressives do not reveal their key themes out of shame, or the therapist does not work on early life experience and unresolved early grief/abuse. Alternatively, even if a patient is prepared to reveal, a therapist may not be prepared to work on historical data for various (usually dogmatic theoretical) reasons.

Life events: Life events may happen at a crucial time during convalescence. For example, a patient had recovered and was doing well when his mother died and he became depressed again. Any of the events that can cause depression can be involved in relapse.

Social support: Increasing evidence is coming through that spouse criticism is a key variable in relapse. Also, living alone and other social factors can contribute to relapse.

Protection/resistance

Biological: Some individuals may be extraordinarily resistant to major depression for biological reasons. Recently, some attention has turned to explore this area rather than focus on depression. As Bebbington et al. (1989) have pointed out, in some areas of social deprivation, resistance is as intriguing as depression.

Personality: Since the time of the Hippocrates it has been known that some people are extremely resilient to depression. These individuals are often social and non-aggressive and have high self-esteem.

Development: Some individuals may have been able to internalise very good selfobject relations and self-esteem as a result of early life. The self-organisation is so strong that it is difficult to switch into depression. It reminds me of the toys that you turn on their side and they immediately flip upright again. They have the capacity for self-soothing, or do not catastrophise or self-down. The issue of brain state switching (Gilbert, 1984) is still to be researched.

Cognitive style: In Seligman’s (1989) view, optimists are less prone to depression. However, it is unclear yet if when they fall they fall into more serious depressions.

Social Life: In some cases a person may be so well integrated with a way of life that provides their sense of self, sense of belonging and purpose that they are never exposed to those events noted for cause. Recent work on cults (e.g., Galanter, 1990) have suggested that this may be one of their positive functions.