Depression. Aaron T. Beck, M.D.

disorder is the leading cause of disability in the established market economies around the world.⁷

      Twelve-month prevalence and severity rates are provided by Kessler et al.⁸ The U.S. National Comorbidity Survey Replication included a nationally representative face-to-face household survey conducted between February 2001 and April 2003. The study employed a structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Participants included 9,282 English-speaking respondents 18 years and older. Twelve-month prevalence and estimates of mood disorders from this study are included in Table 1-3.

TABLE 1-3. Twelve-Month Prevalence and Severity of Mood Disorders (%)

      Adapted from Kessler et al. 2005.

TABLE 1-4. Ages at Selected Percentiles on Standardized Age-of-Onset Distributions of DSM-IV/ WMH-CIDI Mood Disorders, with Projected Lifetime Risk at Age 75 Years

      Adapted from Kessler et al. 2005.

TABLE 1-5. Lifetime Prevalence (%) of Disorders by Age

      Adapted from Kessler et al. 2005.

      Age of onset and lifetime prevalence rates (the likelihood of experiencing a mood disorder at some time in one’s lifetime) are presented in Tables 1-4 and 1-5.⁹

Descriptive Concepts of Depression

      The condition that today we label depression has been described by a number of ancient writers under the classification of “melancholia.” The first clinical description of melancholia was made by Hippocrates in the fourth century B.C. He also referred to swings similar to mania and depression.¹⁰

      Aretaeus, a physician living in the second century A.D., described the melancholic patient as “sad, dismayed, sleepless. . . . They become thin by their agitation and loss of refreshing sleep. . . . At a more advanced stage, they complain of a thousand futilities and desire death.” It is noteworthy that Aretaeus specifically delineated the manic-depressive cycle. Some authorities believe that he anticipated the Kraepelinian synthesis of manic-depressive psychosis, but Jelliffe discounts this hypothesis.

      Plutarch, in the second century A.D., presented a particularly vivid and detailed account of melancholia:

      He looks on himself as a man whom the Gods hate and pursue with their anger. A far worse lot is before him; he dares not employ any means of averting or of remedying the evil, lest he be found fighting against the gods. The physician, the consoling friend, are driven away. ‘Leave me,’ says the wretched man, ‘me, the impious, the accursed, hated of the gods, to suffer my punishment.’ He sits out of doors, wrapped in sackcloth or in filthy rags. Ever and anon he rolls himself, naked, in the dirt confessing about this and that sin. He has eaten or drunk something wrong. He has gone some way or other which the Divine Being did not approve of. The festivals in honor of the gods give no pleasure to him but fill him rather with fear or a fright. (quoted in Zilboorg¹¹)

      Pinel at the beginning of the nineteenth century described melancholia as follows:

      The symptoms generally comprehended by the term melancholia are taciturnity, a thoughtful pensive air, gloomy suspicions, and a love of solitude. Those traits, indeed, appear to distinguish the characters of some men otherwise in good health, and frequently in prosperous circumstances. Nothing, however, can be more hideous than the figure of a melancholic brooding over his imaginary misfortunes. If moreover possessed of power, and endowed with a perverse disposition and a sanguinary heart, the image is rendered still more repulsive.

      These accounts bear a striking similarity to modern textbook descriptions of depression; they are also similar to contemporary autobiographical accounts such as that by Clifford W. Beers.¹² The cardinal signs and symptoms used today in diagnosing depression are found in the ancient descriptions: disturbed mood (sad, dismayed, futile); self-castigations (“the accursed, hatred of the gods”); self-debasing behavior (“wrapped in sackcloth or dirty rags . . . he rolls himself, naked, in the dirt”); wish to die; physical and vegetative symptoms (agitation, loss of appetite and weight, sleeplessness); and delusions of having committed unpardonable sins.

      The foregoing descriptions of depression include the typical characteristics of this condition. There are few psychiatric syndromes whose clinical descriptions are so constant through successive eras of history (For descriptions of depression through the ages, see Burton.¹³) It is noteworthy that the historical descriptions of depression indicate that its manifestations are observable in all aspects of behavior, including the traditional psychological divisions of affection, cognition, and conation.

      Because the disturbed feelings are generally a striking feature of depression, it has become customary to regard this condition as a “primary mood disorder” or as an “affective disorder.” The central importance ascribed to the feeling component of depression is exemplified by the practice of utilizing affective adjective checklists to define and measure depression. The representation of depression as an affective disorder is as misleading as it would be to designate scarlet fever as a “disorder of the skin” or as a “primary febrile disorder.” There are many components of depression other than mood deviation. In a significant proportion of the cases, no mood abnormality at all is elicited from the patient. In our present state of knowledge, we do not know which component of the clinical picture of depression is primary, or whether they are all simply external manifestations of some unknown pathological process.

      Depression may now be defined in terms of the following attributes:

      1. A specific alteration in mood: sadness, loneliness, apathy.

      2. A negative self-concept associated with self-reproaches and self-blame.

      3. Regressive and self-punitive wishes: desires to escape, hide, or die.

      4. Vegetative changes: anorexia, insomnia, loss of libido.

      5. Change in activity level: retardation or agitation.

Semantics of Depression

      One of the difficulties in conceptualizing depression is essentially semantic, namely, that the term has been variously applied to designate a particular type of feeling or symptom; a symptom-complex (or syndrome); and a well-defined disease entity.

      Not infrequently, normal people say they are depressed when they observe any lowering of their mood below their baseline level. A person experiencing a transient sadness or loneliness may state that he or she is depressed. Whether this normal mood is synonymous with, or even related to, the feeling experienced in the abnormal condition of depression is open to question. In any event, when a person complains of feeling inordinately dejected, hopeless, or unhappy, the term depressed is often used to label this subjective state.

      The term depression is often used to designate a complex pattern of deviations in feelings, cognition, and behavior (described in the previous section) that is not represented as a discrete psychiatric disorder. In such instances it is regarded as a syndrome, or symptom-complex. The cluster of signs and symptoms is sometimes conceptualized as a psychopathological dimension ranging in intensity (or in degree of abnormality) from mild to severe. The syndrome of depression may at times appear as a concomitant of a definite psychiatric disorder such as schizophrenic reaction; in such a case, the diagnosis would be “schizophrenic reaction with depression.” At times, the syndrome may be secondary to, or a manifestation of, organic disease of the brain such as general paresis or cerebral artereosclerosis.

      Finally,