Depression. Aaron T. Beck, M.D.

of the body until the skin is worn away.

      They may get out of the chair many times in the course of an interview and pace the floor. At night, they may get out of bed frequently and walk incessantly back and forth. It is just as difficult for them to engage in constructive activity as it is to stay still. Their agitation is also manifested by frequent moans and groans. They approach doctors, nurses, and other patients and besiege them with requests or pleas for reassurance.

      The emotions of frenzy and anguish are congruent with their thought content. They wail, “Why did I do it? Oh, God, what is to become of me? Please have mercy on me.” They believe they are about to be butchered or buried alive. They moan, “My bowels are gone. It’s intolerable.” They scream, “I can’t stand the pain. Please put me out of my misery.” They groan, “My home is gone. My family is gone. I just want to die. Please let me die.”

      The thought content of the retarded patient appears to revolve around passive resignation to his or her fate. The agitated patient, on the other hand, cannot accept or tolerate the torture envisioned. The agitated behavior appears to represent desperate attempts to fight off impending doom.

Variations in Symptoms

Children and Adolescents

      Weiss and Garber²¹ reviewed the empirical findings on whether children and adolescents experience and express depression in the same way as do adults. Although it is commonly accepted that depression occurs in this age group, and that developmental level has relatively little influence on the phenomenology of the depression, the developmental perspective predicts the possibility of unique manifestations and experiences of such. Thus, it is possible that a person’s level of physiological, social, and cognitive development must be taken into account in defining depression.

      Considering over a dozen studies relevant to the question, Weiss and Garber²¹ concluded that the matter remains unresolved: It is not known how depression in childhood and adolescence may differ from that in adults. However, they did articulate the issues. In so doing, they distinguished between continuity within the individual and continuity of the form or nature of depression across developmental levels. Among other examples they provided was anhedonia (lack of pleasure), present at all developmental levels, but expressed differently in each. Young children may express anhedonia by lack of interest in toy play; adolescents may appear bored; adults may lose interest in sex.

      It is important to note that the review and metaanalysis of the empirical literature²¹ did not imply that there are no differences between children and adults in the experience and expression of depression; rather the current state of research is such that unequivocal outcomes have not yet emerged. If differences are found following properly controlled studies, the most essential research question is whether the differences result from the causes or consequences of depression. Before getting to that, however, “the fundamental question of whether there are developmental differences in the symptoms that comprise the syndrome of depression remains to be answered” (p. 427).

      The official diagnostic manual of the American Psychiatric Association (APA)²² is not as circumspect as the reviewers above, asserting instead that the “core symptoms” of a major depressive episode are the same for children and adolescents. However, it is stated that the prominence of characteristic symptoms may change with age: “Certain symptoms such as somatic complaints, irritability, and social withdrawal are particularly common in children, whereas psychomotor retardation, hypersomnia, and delusions are less common in prepuberty than in adolescence and adulthood” (p. 354).

Cultural Variations

      Cultural context must be better understood in order to avoid underdiagnosis or misdiagnosis due to variation in the experience and communication of depressive symptoms.²² The following may serve as concrete examples: “Complaints of ‘nerves’ and headaches (in Latino and Mediterranean cultures), of weakness, tiredness, or ‘imbalance’ (in Chinese and Asian cultures), of problems of the ‘heart’ (in Middle Eastern cultures), or of being ‘heartbroken’ (among Hopi) may [all] express the depressive experience” (p. 353).’ Research is needed to more fully understand the symptoms of depression as expressed in different cultures around the world.

      Chapter 3

      Course and Prognosis

Depression as a Clinical Entity

      In Chapter 2, depression was treated as a psychopathological dimension or syndrome. The clinical features of depression were examined in cross-section, that is, in terms of the cluster of pathological phenomena exhibited at a given point in time. In this chapter, depression is treated as a discrete clinical entity (such as bipolar disorder or dysthymia) that has certain specific characteristics occurring over time in terms of onset, remission, and recurrence. As a clinical entity or reaction type, depression has many salient characteristics that distinguish it from other clinical types such as schizophrenia, even though these other types may have depressive elements associated with them. The depressive constellation as a concomitant of other nosological entities will not be described in this chapter but will be considered later in terms of its association with schizophrenic symptomatology in the schizoaffective category (Chapter 8).

      Among the important characteristics of the clinical entity of depression are the following: There is generally a well-defined onset, a progression in the severity of the symptoms until the condition bottoms out, and then a steady regression (improvement) of the symptoms until the episode is over; the remissions are spontaneous; there is a tendency toward recurrence; the intervals between attacks are free of depressive symptoms.

Importance of Course and Outcome

      The longitudinal aspects of depression have been the subject of many investigations since the time of Kraepelin. Adequate information regarding the short-term and long-term course of depression is important, not only for practical management, but also for an understanding of the psychopathology and for evaluation of specific forms of treatment. Considerable data on the life histories of depressed patients were accumulated before the advent of the specific therapeutic agents—psychological treatments (such as cognitive and interpersonal therapy), electroconvulsive therapy (ECT), and drugs. These data are generally regarded as reflecting the natural history of the disorder, although it is difficult to separate out the effects of hospitalization.

      The physician charged with making a determination of the prognosis in a given case is confronted with a number of questions.

      1. In the case of a first episode of depression, what are the prospects for complete remission, and what is the likelihood of residual symptoms or of a chronic, unrecovered state?

      2. What is the probable duration of the first attack?

      3. What is the likelihood of recurrence, and what is the probable duration of any multiple attacks?

      4. How long must one wait following a patient’s remission from a given attack before ruling out the likelihood of recurrence?

      5. What is the risk of death through suicide?

      Answers to these questions can be provided by reference to research on early cases diagnosed as manic-depressive psychoses and subsequent studies that elaborated the prior findings. A number of fairly well-designed studies have been conducted to determine the fate of such patients. It should be emphasized that much of the available data applies primarily to hospitalized patients.

      A series described by Paskind as “manic depressive” in 1930 undoubtedly contained a preponderance of cases that would later be diagnosed as “neurotic-depressive reactions.” Since this study antedated the modern somatic therapies, the findings may be assumed to be relevant to the natural history of neurotic-depressive reactions.

Systematic Studies

      Kraepelin¹ studied the general course of 899 cases of manic-depressive psychosis. The period of observation varied considerably; some