Depression. Aaron T. Beck, M.D.

or impending shift in a patient’s life situation may serve to mobilize constructive motivations. One notably retarded and apathetic patient was suddenly aroused when her husband became ill and she experienced a strong desire to help him. Another patient experienced a return of positive motivation when informed she was going to be hospitalized, a prospect she viewed as extremely distasteful.

      Mild: Patients find they no longer spontaneously desire to do certain specific things, especially those that do not bring any immediate gratification. An advertising executive observes a loss of drive and initiative in planning a special sales promotion; a college professor finds himself devoid of any desire to prepare his lectures; a medical student loses her desire to study. A retiree who formerly felt driven to engage in a variety of domestic and community projects, described her loss of motivation in the following terms: “I have no desire to do anything. I just do things mechanically without any feeling for what I’m doing. I just go through the motions like a robot and when I run down I just stop.”

      Moderate: In moderate cases the loss of spontaneous desire spreads to almost all of the patient’s usual activities. A woman complained, “There are certain things I know I have to do like eat, brush my teeth, and go to the bathroom, but I have no desire to do them.” In contrast to severely depressed patients, moderately depressed patients find they can “force” themselves to do things. Also, they are responsive to pressure from other people or to potentially embarrassing situations. A woman, for instance, waited in front of an elevator for about 15 minutes because she could not mobilize any desire to press the button. When others approached the elevator, however, she rapidly pressed the button lest they think she was peculiar.

      Severe: In severe cases, there often is complete paralysis of the will. Patients have no desire to do anything, even things that are essential to life. Consequently, they may be relatively immobile unless prodded or pushed into activity by others. It is sometimes necessary to pull patients out of bed, wash, dress, and feed them. In extreme cases, even communication may be blocked by the patient’s inertia. One woman, who was unable to respond to questions during the worst part of her depression, remarked later that even though she “wanted” to answer she could not summon the “will power” to do so.

Avoidance, Escapist, and Withdrawal Wishes

      The wish to break out of the usual pattern or routine of life is a common manifestation of depression. The office assistant wants to get away from paper work, the student daydreams of faraway places, and the stay-at-home spouse yearns to leave domestic tasks. Depressed individuals regard their duties as dull, meaningless, or burdensome and want to escape to an activity that offers relaxation or refuge.

      These escapist wishes resemble the attitudes described as paralysis of the will. A useful distinction is that the escapist wishes are experienced as definite motivations with specific goals, whereas paralysis of the will refers to the loss or absence of motivation.

      Mild: Mildly depressed patients experience a strong inclination to avoid or postpone doing certain things they regard as uninteresting or taxing. They tend to shy away from attending to details they consider unimportant. They are likely to procrastinate or avoid entirely an activity that does not promise immediate gratification or involves effort. Just as they are repelled by activities that involve effort or responsibility, they are attracted to more passive and less complex activities.

      A depressed student expressed this as follows: “It’s much easier to daydream in lectures than pay attention. It’s easier to stay home and drink than call a girl for a date. . . . It’s easier to mumble and not be heard than to talk clearly and distinctly. It’s much easier to write sloppily than to make the effort to write legibly. It’s much easier to lead a self-centered, passive life than to make the effort to change it.”

      Moderate: In moderate cases, avoidance wishes are stronger and spread to a much wider range of usual activities. A depressed college professor described this as follows: “Escape seems to be my strongest desire. I feel as though I would feel better in almost any other occupation or profession. As I ride the bus to the university, I wish I were the bus driver instead of a teacher.”

      Patients think continually of ways of diversion or escape. They would like to indulge in passive recreation such as going to the movies, watching television, or getting drunk. They may daydream of going to a desert island or becoming a hobo. At this stage, they may withdraw from most social contacts since interpersonal relations seem to be too demanding. At the same time, because of their loneliness and increased dependency, they may want to be with other people.

      Severe: In severe cases, the wish to avoid or escape is manifested in marked seclusiveness. Not infrequently the patient stays in bed, and when people approach, may hide under the covers. A patient said, “I just feel like getting away from everybody and everything. I don’t want to see anybody or do anything. All I want to do is sleep.” One form of escape that generally occurs to severely depressed patients is suicide. They feel a strong desire to end their life as a way of escaping from a situation they regard as intolerable.

Suicidal Wishes

      Suicidal wishes have historically been associated with a depressed state. While suicidal wishes may occur in nondepressed individuals, they occur substantially more frequently in depressed patients. In our series this was the symptom reported least frequently (12 percent) by the nondepressed patients, but it was reported frequently (74 percent) by the severely depressed patients. This difference indicates the diagnostic value of this particular symptom in the identification of severe depression. The intensity with which this symptom was expressed also showed one of the highest correlations with the intensity of depression.

      The patient’s interest in suicide may take a variety of forms. It may be experienced as a passive wish (“I wish I were dead”); an activity wish (“I want to kill myself”); as a repetitive, obsessive thought without any volitional quality; as a daydream; or as a meticulously conceived plan. In some patients, the suicidal wishes occur constantly throughout the illness, and the patient may have to battle continually to ward them off. In other cases, the wish is sporadic and is characterized by a gradual build-up, then a slackening of intensity until it disappears temporarily. Patients often report, once the wish has been dissipated, that they are glad they did not succumb to it. It should be noted that the impulsive suicidal attempt may be just as dangerous as the deliberately planned attempt.

      The importance of suicidal symptoms is obvious, since nowadays it is practically the only feature of depression that poses a reasonably high probability of fatal consequences. The incidence of suicide among manic depressives ranged from 2.8 percent in one study with a 10-year follow-up¹² to 5 percent in a 25-year period of observation.¹³

      Mild: Wishes to die were reported by about 31 percent of the mildly depressed patients. Often these take the passive form such as “I would be better off dead.” Patients may state that they would not do anything to hasten death, but find the idea of dying attractive. One patient looked forward to an airplane trip because of the possibility the plane might crash.

      Sometimes the patient expresses an indifference toward living (“I don’t care whether I live or die”). Other patients may show ambivalence (“I would like to die but at the same time I’m afraid of dying”).

      Moderate: In these cases, suicidal wishes are more direct, frequent, and compelling; there is a definite risk of either impulsive or premeditated suicidal attempts. The patient may express this desire in the passive form: “I hope I won’t wake up in the morning” or “If I died, my family would be better off.” The active expression of the wish may vary from an ambivalent statement, “I’d like to kill myself but I don’t have the guts,” to the bald assertion, “If I could do it and not botch it up, I would go ahead and kill myself.” The suicidal wish may be manifested by the patient’s taking unnecessary risks. A number of patients drove their cars at excessive rates of speed in the hope that something might happen.

      Severe: In severe cases, suicidal wishes tend to be intense, although the patient may be too retarded to complete a suicidal attempt. Among typical statements are the following: “I feel so hopeless. Why won’t