Depression. Aaron T. Beck, M.D.

Tables 1-4, 1-5 from Kessler RC, Berglund P, Demler O, Jin R, Walters EE, Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication Archives of General Psychiatry 2005;62,593–602.

      Table 3.5 from Lundquist G, Prognosis and course in manic-depressive psychoses. Acta Psychiat. Neurol. Suppl. 1945;35.

      Table 3-6 from Kiloh G, Andrews G, Neilson M, The long-term outcome of depressive illness, British Journal of Psychiatry 1988;153:752–757.

      Table 3-7 from Riso LP, Blandino JA, Penna S, Dacey S, Grant MM, Toit PL, Duin JS, Pacoe EM, Ulmer CS, Cognitive aspects of chronic depression. Journal of Abnormal Psychology 2003;112:72–80 (by permission of American Psychological Association).

      Tables 8-2, 8-3 from Bertelsen A, Gottesman II, Schizoaffective psychoses: genetical clues to classification. American Journal of Medical Genetics 1995;60:7–11.

      Table 9-2 from McGuffin P, Rijsdijk F, Andrew M, Sham P, Katz R, Cardno A, The heritability of bipolar affective disorder and the genetic relationship to unipolar depression. Archives of General Psychiatry 2003;60:497–502.

      Tables 14-2, 14-5 from Masand PS, Gupta S, Selective serotonin-reuptake inhibitors: an update. Harvard Review of Psychiatry 1999;7:69–84 (by permission of Taylor & Francis Group, LLC).

      Table 14-3 from Johnson GF. Lithium in depression: A review of the antidepressant and prophylactic effects of lithium. Australian and New Zealand Journal of Psychiatry 1987;21:356–365.

      Table 14-7 from Baldessarini RJ, Tonodo L, Hennen J, Viguera AC, Is lithium still worth using? an update of selected recent research. Harvard Review of Psychiatry 2002;10:59-75 (by permission of Taylor & Francis Group, LLC).

      Part I

       Clinical Aspects of Depression

      Chapter 1

      The Definition of Depression

Paradoxes of Depression

      Depression may someday be understood in terms of its paradoxes. There is, for instance, an astonishing contrast between the depressed person’s image of him- or herself and the objective facts. A wealthy woman moans that she doesn’t have the financial resources to feed her children. A widely acclaimed movie star begs for plastic surgery in the belief that he is ugly. An eminent physicist berates herself “for being stupid.”

      Despite the torment experienced as the result of these self-debasing ideas, the patients are not readily swayed by objective evidence or by logical demonstration of the unreasonable nature of these ideas. Moreover, they often perform acts that seem to enhance their suffering. The wealthy man puts on rags and publicly humiliates himself by begging for money to support himself and his family. A clergyman with an unimpeachable reputation tries to hang himself because “I’m the world’s worst sinner.” A scientist whose work has been confirmed by numerous independent investigators publicly “confesses” that her discoveries were a hoax.

      Attitudes and behaviors such as these are particularly puzzling—on the surface, at least—because they seem to contradict some of the most strongly established axioms of human nature. According to the “pleasure principle,” patients should be seeking to maximize satisfactions and minimize pain. According to the time-honored concept of the instinct of self-preservation, they should be attempting to prolong life rather than terminate it.

      Although depression (or melancholia) has been recognized as a clinical syndrome for over 2,000 years, as yet no completely satisfactory explanation of its puzzling and paradoxical features has been found. There are still major unresolved issues regarding its nature, its classification, and its etiology. Among these are the following:

      1. Is depression an exaggeration of a mood experienced by the normal, or is it qualitatively as well as quantitatively different from a normal mood?

      2. What are the causes, defining characteristics, outcomes, and effective treatments of depression?

      3. Is depression a type of reaction (Meyerian concept), or is it a disease (Kraepelinian concept)?

      4. Is depression caused primarily by psychological stress and conflict, or is it related primarily to a biological derangement?

      There are no universally accepted answers to these questions. In fact, there is sharp disagreement among clinicians and investigators who have written about depression. There is considerable controversy regarding the classification of depression, and a few writers see no justification for using this nosological category at all. The nature and etiology of depression are subject to even more sharply divided opinion. Some authorities contend that depression is primarily a psychogenic disorder; others maintain just as firmly that it is caused by organic factors. A third group supports the concept of two different types of depression: a psychogenic type and an organic type.

Prevalence of Depression

      The importance of depression is recognized by everyone in the field of mental health. According to Kline,¹ more human suffering has resulted from depression than from any other single disease affecting humankind. Depression is second only to schizophrenia in first and second admissions to mental hospitals in the United States, and it has been estimated that the prevalence of depression outside hospitals is five times greater than that of schizophrenia.² Worldwide, Murray and Lopez³ found unipolar major depression to be the leading cause of disability in 1990, measured in years lived with a disability. Unipolar depression accounted for more than one in every ten years of life lived with a disability.

      More than 40 years ago, a systematic survey of the prevalence of depression in a sharply defined geographical area indicated that 3.9 percent of the population more than 20 years of age were suffering from depression at a specified time.⁴ According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association,⁵ the probability during one’s lifetime of developing a major depressive disorder is 5–12 percent for males and 10–25 percent for females. At any given point in time (“point prevalence”), 2–3 percent of the male and 5–9 percent of the female population suffer from a major depression. Piccinelli⁶ reviewed the studies on gender differences in depression and found that the gender differences began at mid-puberty and continued through adult life.

TABLE 1-1. Leading Causes of Disability Worldwide, 1990

      Adapted from Lopez and Murray 1998. For up-to-date WHO data, see http://www.who.int/mental_health/management/depression/definition/en/

      TABLE 1-2. Prevalence of Major Depressive Disorder by Gender (%)

      Adapted from DSM-IV-TR.

Prevalence and Severity by Types and Age at Onset

      Lifetime prevalence rates for the other mood disorders (see Chapter 4 for distinctions among types) are reported in DSM-IV⁵ as follows: Dysthymic disorder 6 percent; Bipolar I 0.4–1.6 percent; Bipolar II 0.5 percent; Cyclothymic 0.4–1.0 percent. The National Institute of Mental Health (USA)⁷ reports that 18.8 million American adults (9.5 percent of the population age 18 or older) in a given year suffer from