Nature of Depression
Seligman (1973) referred to depression as the ‘common cold’ of psychiatry because of
its frequency of diagnosis. According to BPS figures a staggering 9 million people in
Britain reported feelings of depression to their GP in 1998! However to continue
Seligman’s analogy, although this ‘cold’ may have reached epidemic proportions in the
West it is certainly not pandemic since many cultures and areas of the World report little
or no depression
Characteristics of depression
Depression is an affective disorder in that it is characterized by disturbances of affect (or
mood). During the course of any period of time it is not unusual for a person’s mood to
alter. However with affective disorders this variation is more marked and is
accompanied by other symptoms.
These symptoms of depression do vary; the DSM-IV recognize three main types of
depression, only two of which will be mentioned here, and only one of which will be
covered in detail. A possible 6 mark question on the paper could ask you to describe
the symptoms or characteristics of depression. Clearly ‘feeling sad’ is not going to earn
you very much credit!
The symptoms we most associate with depression, those feelings of sadness, loss of
mood and loss of pleasure from what were previously enjoyable activities. Mood may
also alter during the course of the day, typically being lowest in the morning and
gradually showing improvement as the day progresses. This may be associated with
Disturbances of sleep: patients sometimes report insomnia, but sleeping longer than
before is also common, perhaps as patients attempt to escape their problems.
Appetite can also decrease or it may increase in the form of comfort eating. Part of this
may be due to boredom since typically depressed people tend to have lower activity
Apathy and loss of drive are common. Typically the depressed person will sit around
waiting for things to happen, making no attempt to initiate activity or social contact. This
could be because they don’t want people to see them in a depressed state.
These can vary from negative self-thoughts, loss of self-esteem and self-confidence,
feelings of despair and hopelessness, inability to concentrate on tasks for any length of
time to feelings of inadequacy and blaming themselves for their situation and on
occasions and suicidal thoughts.
PSYCHOLOGICAL EXPLANATIONS OF DEPRESSION
To read up on psychological explanations of depression, refer to pages 441–451 of
Eysenck’s A2 Level Psychology.
How would the psychodynamic approach explain depression?
How would the behavioural approach explain depression?
How would the cognitive approach explain depression?
What you need to know
C EXPLANATION APPROACH
Freud argued that individuals whose needs weren’t met during the oral stage of
psychosexual development are vulnerable to developing depression in adulthood
because this causes low self-esteem and excessive dependence.
Individuals whose needs were met to excess during the oral stage are also vulnerable
because they might become too dependent on others. According to Freud, we are
victims of our feelings, as repression and displacement are defence mechanisms in
response to actual loss (death of a loved one) and symbolic loss (loss of status) that
enable us to cope with the emotional turmoil, but can result in depression.
Individuals who are excessively dependent on other people are especially likely to
develop depression after such a loss. Anger at the loss is displaced onto the self, which
affects self-esteem and causes the individual to re-experience loss that occurred in
childhood. Freud believed the superego (or conscience) is dominant in the depressed
person and this explains the excessive guilt experienced by many depressives. In
contrast, the manic phase occurs when the individual’s ego, or rational mind, asserts
itself and he/she feels in control.
EVALUATION OF THE PSYCHODYNAMIC EXPLANATION
Has face validity. This approach does have face validity, as, even if a
psychodynamic approach is not favoured, it is widely accepted that childhood
experience can predispose the individual to mental illness in adulthood. For
example, Kendler et al. (1996, see A2 Level Psychology page 442) found adult
female twins who had experienced parental loss through separation in childhood
had an above-average tendency to suffer from depression in adult life.
Early loss does not consistently predict depression. Fewer than 10% of
individuals who experience major losses go on to develop clinical depression.
Freud predicts that the individual’s anger is turned inwards on themselves yet
often it is turned outwards on those who are closest instead.
The key weakness of Freud’s theory is that it lacks empirical support and
so is neither verifiable nor falsifiable. Furthermore, any link between loss in
childhood and depression is just an association, not causation, and so we cannot
conclude cause and effect.
According to this approach, depression is due to maladaptive learning. The principles of
operant conditioning have been applied to explain depression using reinforcement and
punishment. Depression could be due to a lack of positive reinforcement or too much
RESEARCH EVIDENCE FOR THE BEHAVIOURAL APPROACH
Lewinsohn (1974, see A2 Level Psychology page 443) suggests that depression
is due to a reduction in positive reinforcement as a consequence of some form of
loss, e.g. redundancy, relationship breakdown. Also, once depressed, the
individual may receive positive reinforcement such as sympathy and attention.
Learned helplessness occurs when an individual is placed in a no-win
(punishing) situation. When the individual associates a lack of control with a
situation, e.g. when punishment is seen as unavoidable, passive, helpless
behaviour is shown. Seligman (1975, see A2 Level Psychology page 444) tested
his theory by exposing dogs to electric shocks they could not avoid. When they
were then given the opportunity to avoid the shocks by jumping over a barrier the
dogs did not learn to do this, whereas dogs not exposed to unavoidable shocks
readily learned to avoid them. Seligman generalised this to depression in
humans. Stressful experiences may be experienced as unavoidable and
uncontrollable and so result in learned helplessness, which leads to depression.
Hiroto (1974, see A2 Level Psychology page 444) used three groups of human
participants: (1) exposed to a loud noise they couldn’t stop; (2) exposed to a loud
noise they could stop by pushing a button; and (3) didn’t hear a loud noise. All
participants were then placed in front of a rectangular box with a handle on of it
and exposed to loud noise. Unknown to the participants, the noise could be
switched off by moving the handle from one side to the other. Only the group
previously exposed to a loud noise they couldn’t stop showed learned
helplessness by failing to move the handle.
RESEARCH EVIDENCE AGAINST THE BEHAVIOURAL APPROACH
Many people suffer loss without becoming depressed, which the theory on
reinforcement reduction cannot explain.
Lewinsohn, Hoberman, and Rosenbaum (1988, see A2 Level Psychology page
444) have provided evidence that contradicts the role of reinforcement.
Lewinshohn et al. assessed over 500 non-depressed people for risk factors
associated with depression (e.g. reductions in reinforcement; negative thinking;
life stress), re-assessing them 8 months later to see if they had developed
depression. They found reductions in positive reinforcement did not predict
Research into the role of cognitive factors in depression suggests that selfperception and faulty thinking may be more influential than learned helplessness
and may account for why this develops. Abramson, Seligman, and Teasdale
(1978, see A2 Level Psychology page 445) have expanded upon Seligman’s
theory of learned helplessness with the attribution model, which does account for
EVALUATION OF THE BEHAVIOURAL APPROACH
Reductionist. The behavioural explanations are greatly oversimplified as they
focus on only one factor, the environment. This focus on the external means
internal factors that may be more influential, such as biological and cognitive, are
Environmentally deterministic. The behavioural explanations are deterministic
as they suggest that behaviour is controlled by the environment, which ignores
the individual’s ability to control their own behaviour.
Ignores nature. The behavioural explanations overemphasise nurture and
Extrapolation. The generalisability of Seligman’s research is an issue as there
are qualitative differences between humans and animals.
Face validity. The symptoms in depression do appear similar to the responses
shown by Seligman’s dogs and so the behavioural explanations do have face
validity. It seems likely that a perceived inability to control stressful situations is
common to learned helplessness and depression.
Ecological validity. Seligman’s research lacks mundane realism so may not be
generalisable to real-life settings, and therefore may lack ecological validity.
Population validity. Learned helplessness as an explanation of the
development of depression may be more relevant to certain types of people, e.g.
those who lack social skills and so have limited emotional support.
Cause or effect? Causation cannot be inferred as associations only have been
identified. The lack of reinforcement experienced in social interactions or the
tendency to feel helpless may be a consequence of being depressed rather than
a cause. Consequently, the behavioural explanations may be more relevant to
the maintenance than the onset of depression.
Cognitive dysfunction in attributional style (Abramson et al.’s attribution model) and view
of self, the world, and the future (Beck’s cognitive triad) have been linked to the
development of depression. Negative schemas develop during childhood as a
consequence of critical interpersonal experiences, and are activated when the individual
experiences similar situations in later life.
RESEARCH EVIDENCE FOR COGNITIVE EXPLANATIONS
Abramson, Seligman, and Teasdale (1978, see A2 Level Psychology page 445)
developed Seligman’s work with the attribution model, which considers how
people respond to failure. Individuals susceptible to depression attribute failure to
internal (my own fault), stable (things will never change), and global (applies the
failure to a wide range of situations, e.g. “I’m rubbish at everything”) causes.
Such thinking is more negative and self-critical than attributing experience to
external, unstable, and specific causes. This suggests that aversive stimuli on its
own doesn’t cause learned helplessness and depression, as this is dependent on
how the individual thinks. Hence, the attribution model supports the role of
cognitive factors and improves on the original learned helplessness theory.
Abramson, Metalsky, and Alloy (1989, see A2 Level Psychology page 445)
developed the original theory because they attached less importance to specific
attributions and more importance to the notion that depressed individuals
develop a general sense of hopelessness.
Beck and Clark (1988, see A2 Level Psychology page 446) proposed the
“cognitive triad”, which is the individual’s thoughts about self, world, and future.
The more negative and therefore the more hopeless the cognition, the greater
the risk of depression. Beck also identified errors in logic or cognitive biases,
such as magnification, minimisation, and personalisation, where weaknesses are
exaggerated and strengths under-emphasised. Polarised thinking is another bias,
which is also known as black-and-white thinking. For example, depressives often
set themselves unattainable standards such as, “I must be liked by everybody; if
not I’m unlovable”.
A prospective study by Lewinsohn, Joiner, and Rohde (2001, see A2 Level
Psychology page 446) measured negative or dysfunctional attitudes in
participants who did not have a major depressive disorder at the outset of the
study. They re-assessed the participants 1 year later and found those high in
dysfunctional attitudes were more likely to develop major depression in response
to negative life events. This supports faulty cognition as a cause rather than an
effect of depression.
Evans et al. (2005, see A2 Level Psychology pages 446–447) also conducted a
prospective study and found that women with the highest scores for negative
self-beliefs during pregnancy were 60% more likely to become depressed
subsequently than those with the lowest scores.
RESEARCH EVIDENCE AGAINST COGNITIVE EXPLANATIONS
Much of the evidence suggests that negative thoughts and attitudes are caused
by depression rather than the opposite direction of causality, and so are an effect
of the disorder.
EVALUATION OF COGNITIVE EXPLANATIONS
Face validity. Depressive people do have the negative cognitions described by
Abramson et al. and Beck and so there is a high level of face validity.
Success of cognitive treatments. Cognitive behavioural therapy (CBT) has
been found to be as effective as antidepressants, which supports the role of
cognitive factors in depression.
Self-report criticisms. Research into cognitive factors relies on self-report, e.g.
the Beck Depression Inventory. The self-report method yields subjective data as
it is vulnerable to bias and distortion as a consequence of researcher effects and
participant reactivity and so may lack validity.
Lack of reliability. The research is inconsistent and so we cannot be sure if
negative cognitions cause or are a consequence of depression.
Cause or effect? The evidence that negative cognitions precede the disorder is
not convincing but nor has it been disproved. Therefore, conclusions are limited.
It may be that the relationship is curvilinear, i.e. negative thinking predisposes
depression and depression increases negative thinking.
Descriptive not explanatory. The research describes the nature of depressives’
thoughts rather than explains the development of depression because it is not
clear what causes the negative cognitions in the first place.
Multi-dimensional approach. To account fully for depression it is necessary to
consider how cognition interacts with other approaches. For example, faulty
thinking could be due to an interaction of biological and social factors, which are
ignored by the cognitive approach.
Depression is often preceded by a high number of stressful life events. Interviews of
depressed women showed that 61% of the depressed women had experienced at least
one very stressful life event compared to only 19% of the non-depressed women. Social
support was identified as a variable that protected against depression, as only 10% of
women with a close friend became depressed compared to 37% of those without an
intimate friend (Brown & Harris, 1978, see A2 Level Psychology page 447).
However, as you may remember from studying stress at AS, we are only as stressed as
we think ourselves to be. Thus, the critical mediating factor may be self-perception,
which suggests that cognitive factors predispose the individual to depression more than
the life events themselves as it is the way we think about them that is crucial. This partly
accounts for why people can experience very similar stressful situations and some
become depressed whereas others don’t.
However, to account fully for such variation the interaction of biological predisposing
factors (innate physiological reactivity) and environmental factors (stress) needs to be
considered. Further limitations of the life events research include the fact that the
information is obtained retrospectively several months afterwards, and so there might
be problems remembering clearly what happened. Cause and effect is an issue
because it is unclear whether life events have caused depression or depression caused
the life events. For example, marital separation might cause depression, but depression
can play an important role in causing marital separation.
According to socio-cultural theorists (e.g. Nolen-Hoeksema, 1990, see A2 Level
Psychology page 448), the incidence of major depressive disorder is influenced strongly
by social and cultural factors. An example of a social factor is the presence of an
intimate friend because this has been found to reduce incidence of depression (Brown &
Harris, 1978, see A2 Level Psychology page 448).
Marital status is another important social factor. Blazer et al. (1994, see A2 Level
Psychology page 448) found that divorced individuals were more depressed than
individuals who were married or who had never been married. However, we cannot be
sure of the direction of effect, i.e. if divorce triggered depression or if depression led to
Culture has an effect on the nature of the symptoms reported because individuals in
non-Western countries report mostly physical symptoms (e.g. fatigue, sleep
disturbances), whereas guilt and self-blame are more common symptoms in Western
A sub-cultural factor is evident in the fact that major depression is twice as common in
women in most countries of the world (Hammen, 1997, see A2 Level Psychology page
448). Note you could consider this as an issue of bias in terms of diagnosis as it may be
women are just more likely than men to be diagnosed with depression. However, the
arguments against this are many as maybe women are more likely than men to report
their emotional problems. Or maybe women have more reasons than men to be
depressed, given that they are exposed to more stressors than men are, e.g. gender
bias in the workplace, the triple burden of work, home, and child care, and the fact they
are often poorer than men.
Kendler et al. (1993, see A2 Level Psychology page 449) found that women reported
significantly more negative life events than men in the past year. It is also possible that
women rely on a more emotion-focused approach and so spend a lot of time thinking
about their problems and focus excessively on their emotions. Whereas men are more
problem-focused, or if they do take an emotion-focused approach they seek distraction
from their problems (e.g. drinking alcohol) (Nolen-Hoeksema, 1991, see A2 Level
Psychology page 449).
So what does this mean?
Now that we have covered psychological factors, it is no doubt clear there are
numerous possible contributing factors to depression, which of course makes it all the
more difficult to explain the disorder.
The diathesis–stress model offers a more comprehensive account because it considers
the interaction of nature and nurture. This better accounts for individual differences,
particularly in those who share genes in common, such as identical twins where one
develops depression and the other doesn’t. The diathesis–stress model can explain this
because, whilst both twins will have inherited the genetic component, they may
experience different interactions within the family or stressful life events. Consequently,
the predisposition may be triggered in one twin but not the other.
Genetic predispositions may interact with the psychological explanations as faulty
cognitions and negative family interactions may be linked to genetics. Thus, a multidimensional approach is essential as multiple factors interact to explain the disorder. It
is also worth noting that an idiographic (individually-specific) rather than a nomothetic
(universal) approach is needed as the factors will interact in different ways for different
cases of depression.
Psychological Treatments for Depression
Cognitive Behaviour Therapy (CBT)
CBT is currently seen as being the most effective psychological method of treating
depression. Originally devised by Aaron T. Beck it combines primarily the cognitive
model with aspects of psychoanalysis and behaviour therapy.
The basic aim of CBT is ‘cognitive restructuring’ designed to bring about ‘lasting
changes in target emotions and behaviour’ (Wessler 1986). To this end the therapist
and the patient (from here on in referred to as ‘the client’) form a relationship in which
the irrational and overly negative beliefs of the client are recognized and challenged by
CBT has been widely used by many therapists for many years. During that time it has
undergone many revisions with each therapist tailoring the procedure to their own
needs. As a result there are many forms of CBT in use. However, they all have various
characteristics in common and Beck and Weishaar (1989) suggest the following five
Patients are taught to:
1. Monitor their negative and automatic cognitions
2. Recognise the link between cognitions, affect (mood) and behaviour
3. Consider evidence for and against these automatic thoughts
4. Replace biased thoughts with more realistic ones
5. Learn to identify and then change the beliefs that predispose the client to
Making the client aware of the way cognitive and behavioural aspects feed into mood is
referred to as the educational phase.
Thought catching (cognitive element)
Considers the link between irrational thinking and low mood. Typically the therapist will
set homework in which the client is set clear and achievable goals such as talking to a
member of the opposite sex or a stranger or perhaps recognising their automatic
thoughts and challenging these. Homework extends the therapy into everyday life.
However, the therapist needs to be certain that the homework set is realistic. Setting a
task that cannot be achieved is likely to reinforce the client’s negative thinking still
Behavioural activation (behaviourist element)
The client is encouraged to take part in enjoyable activities. It is common for patients
with depression to cut themselves off and stop socialising. Here the therapist
encourages the client to get out and engage in activities that they enjoyed before the
depression. For example, play sports, go to the cinema, socialise with friends..
Exercise is seen as being particularly beneficial:
Babyak et al (2006) randomly allocated 156 depressed patients into one of three
1. Four months of aerobic exercise
2. Drug treatment
3. Combination of exercise and drug treatment
After the four months all showed significant improvement. Six months later when the
patients were revisited the groups taking exercise had a significantly lower level of
With CBT there are usually about 20 sessions followed by ‘boosters’ in the first year to
help prevent relapse.
Does CBT work?
An early study by Rush et al (1977) showed CBT to be more effective in reducing low
mood than the drug imimprimine (a tricyclic). However, in this particular study the most
striking feature was the lack of success of the drug!
Elkin (1994) made a similar comparison and found that both CBT and imiprimine
resulted in ‘almost complete removal’ of depressed symptoms in 55% of patients. Both
were significantly better than placebo, but the drug did work faster.
Hollon et al (2005)
This will sound familiar because we’ve looked at it as evidence for the effectiveness of
drugs, but here it is again. Depressed patients were treated for 16 weeks. They
An SSRI (paroxetine) or Cognitive therapy
Similar numbers of each group (about 60%) showed considerable improvement. These
successes were then followed up for a further 12 months. See above for further details
What this tells us
When CBT was stopped and no further treatment was received, relatively few suffered
relapse into depression. This suggests that cognitive therapy has dealt with
the cause of the depression.
When drug therapy is given and maintained relapse rate is relatively low (though not as
low as therapy) which suggests the drugs are working provided they are maintained.
The most telling figure however, is the 76% that relapse when the drugs are withdrawn.
This confirms that drugs are fine until medication stops. During the prescribed period
the drugs are reducing the symptoms but not dealing with the causes. If they were then
the patient would be fine when medication stopped. In fact three quarters of patients
become depressed again. Drugs appear to be palliative. This suggests that CBT is to
be preferred to drugs.
Further evidence for the curative nature of CBT was produced by Segal et al (2005).
Groups of patients were treated with either CBT or drugs. As with the Hollon study, both
were similarly successful.
Later the recovered patients were ‘made to feel sad.’* Those who had been treated with
drugs returned to their negative and dysfunctional thinking (evidence for palliative)
whereas those who had received CBT remained more positive and rational (evidence
*Was intrigued as to how they did this… here’s the answer: ”Patients listened through
headphones to a piece of music presented on a CD player while following instructions
to recall a time in their lives when they felt sad. The piece of music was “Russia under
the Mongolian Yoke,” composed by Sergei Prokofiev. This piece was re-mastered at
half speed and runs for approximately 8 min. This piece, played at half speed, has been
shown to be very effective in inducing a negative or depressed mood.”
Appropriateness of CBT
On the face of it, it seems to be the most appropriate given that so many symptoms of
depression are cognitive in nature. It is also worth mentioning that CBT also tackles the
behavioural components such as seeking to encourage greater contact and interactions
with others and seeking more pleasurable activities.
CBT might not be suitable for everyone. It does require a certain level of intelligence
and an ability to be introspective as well as to be able to communicate your thoughts
Note: a lot is made in the literature about the competence of the therapist in ensuring a
positive outcome. However, there have been recent and successful attempts to
produce more automated forms of CBT that can be delivered online. This would seem
to negate the need for a therapist at all!
One of the biggest issues with CBT is the cost, particularly in the UK where health care
is delivered by the NHS at the taxpayer’s expense. Whitfield and Williams (2003) found
evidence that the NHS was struggling to provide CBT on a weekly basis to the many
patients that would clearly benefit from the procedure.
Recently there have been attempts to train other health care workers in the basics of
CBT so it can be administered more widely. One such initiative is SPIRIT (Structured
Psychosocial InteRvention In Teams). Their acronym not mine!
This is a training programme designed to run for just under 40 hours together with 5
hours of clinical supervision in the administering of the therapy. Medical professionals
are taught how to build relationships with their clients and how to use Beck’s techniques
to alter distorted thinking. This does illustrate however, how popular the therapy has
The initiative, running in Glasgow, is still in its early days (as of February 2013).
One final weakness:
Many problems leading to depression centre on dysfunctional and failing personal
relationships with others. CBT generally overlooks these so might not be as effective in
dealing with depression with these causes. The next therapy specialises in depression
caused by relationship issues.
Psychodynamic Interpersonal Theory (PIT)
Devised by Hobson (1985) and originally called ‘conversation model’ since it is based
on the therapist and patient having a ‘therapeutic conversation.’
The basic assumption of the treatment is that depression arises from disruption of
personal relationships. These are explored during therapy as part of another
relationship, the one between therapist and patient.
The treatment is designed as a short term measure that explores past relationships,
particularly those during childhood and adolescence, many of which might have failed.
Its primary aim is to reduce the symptoms of depression ad improve social adjustment.
PIT claims to produce more satisfying current relationships by exploring what has gone
wrong with previous ones.
In order to keep the therapy as brief as possible, the patient and therapist agree during
the first few sessions which relationships will be explored. Future sessions then
concentrate on these. In this way, PIT is unlike the more typical open-ended therapies
preferred by the psychodynamic approach.
Three components of depression
1. Development of symptoms due to biological, genetic and/or psychodynamic
2. Social interactions that are learned and change over the course of a lifetime
3. Personality; the enduring dispositional characteristics which may predispose a
person to depression
IPT tackles the first two. It doesn’t consider or attempt to influence personality.
Although PIT has been used to treat a host of psychological issues such as eating
disorders, panic disorder and issues relating to HIV, its main focus has always been on
depression. In particular PIT is designed to manage four basic problem areas:
1. Unresolved grief
Grief is normal following bereavement. However, this considers delayed grief or grief
that has become distorted. For example grief that lacks sadness but manifests itself in
non-emotional ways such as odd behaviours.
Aim of PIT: to facilitate mourning
2. Role disputes
When there are differing expectations about the nature or outcome of a relationship
between the people involved. Perhaps one wanting it to become more serious when
the other doesn’t.
Aim of PIT; to recognise the nature of the dispute and decide a plan of action that will
resolve the misunderstanding.
3. Role transitions
Depression caused by an inability to cope with life changes and events. Typical
examples would include divorce, retirement, leaving home. The depressed person is far
more likely to see these as a loss rather than an opportunity.
Aim of PIT: Get the patient to give up the old role and accompanying sadness, guilt or
4. Interpersonal deficits
The patient has too few or total lack of supportive relationships, for example no intimate
relationships resulting in feelings of inadequacy and low self-esteem.
Aim of PIT: to reduce social isolation. In this case PIT is more likely to focus on past
Does PIT work?
Paley et al (2008) concluded that PIT is as effective as CBT.
They followed 62 patients over a 52 month period. The effectiveness of the PIT was
measured using the BDI (Beck Depression Inventory). 34% of patients showed
significant reduction in depressed symptoms.
However, this study was poorly controlled (by the authors’ own admission) so it is
difficult to be certain that it was just the PIT bringing about the improvements.
Brief interventions can also be useful. 54 NHS patients were either given 12 weeks of
PIT or placed on a waiting list for treatment (control group).
In the 33 patients that completed the study there were significant improvements.
However, there was a very high drop out rate, mostly from the ones on the waiting list.
Many psychologists consider CBT to be too limited in its approach, considering mostly
the cognitive processes underlying the negative cognitions. PIT recognises the
importance of relationships in the development and treatment of depression so adds a
new dimension to therapy.
PIT is especially useful in depression known to be at least partly due to relationship
issues, such as divorce and bereavement.