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Coping With The Catch-22s of Depression: A Guide For Educating Patients
Coping With The Catch-22s of Depression: A Guide For Educating Patients
Coping With The Catch-22s of Depression: A Guide For Educating Patients
Allen
depression,” the gist of which is that all the things one must do to re-
cover from depression are made difficult by the symptoms of depres-
sion. A glaring example: Hope sustains recovery, and depression
brings hopelessness.
Starting out in a relatively long-term specialized inpatient program
(Allen, Coyne, & Console, 2000), the trauma education program was
highly ambitious. The group met twice weekly to cover the full curricu-
lum in an academic year. Even with long-term treatment, patients were
exposed only to a portion of the material in the group meetings. Thus it
became necessary to have written material that would cover the full
course, which ultimately became a book-length manuscript (Allen,
1995). When we subsequently implemented the trauma education pro-
gram on an acute inpatient unit, we devoted even greater emphasis to
depression, given that patients were typically admitted for acute exacer-
bations. As we explained it to patients, severe depression becomes a top
priority in treatment because it is potentially fatal if associated with sui-
cidal states, and at least partial recovery from depression is necessary to
work productively on the problems that precipitated the depression. In
the context of educating patients in acute treatment, we developed vid-
eotapes on trauma and depression to provide patients with a quick
overview. A simple “stress pileup” model (Allen, 2001) served to pro-
vide a quick, yet comprehensive, overview of the multiple pathways to
depression.
Having refined the depression component of the trauma education
program, we then added this psychoeducational intervention to the
Professionals in Crisis Program, an inpatient program where patients
typically remain for a few weeks. The group meets once weekly, and the
curriculum spans several weeks. Thus the written handout provides the
full course content for patients who attend only a portion of the ses-
sions. The process is similar to that in the trauma education groups (Al-
len, 2001) inasmuch as the leader presents some core concepts and
patients are encouraged to discuss how these concepts relate to their
personal experience. Plainly, given their extensive experience, the pa-
tients are the experts. At their best, these group meetings become rather
discursive brainstorming sessions in which we pool our expertise to
deepen our conjoint understanding of the challenges in recovering from
depression. As we continue to expand our knowledge, I endeavor to
pass on whatever I learn.
What follows is the text that we have developed as a handout for pa-
tients participating in a psychoeducational group on depression in the
Professionals in Crisis program at The Menninger Clinic. Citations and
the professional formulations behind that text are detailed in an accom-
panying appendix.
you respond to treatment, the choices become easier, and you have
more strength and ability to climb.
Keep in mind the catch-22s. It’s hard to climb a mountain when
you’re exhausted. One of the most demoralizing aspects of depression is
its persistence and recurrence. Many persons have worked hard and
successfully over a long period of time to fight depression. They become
demoralized when they become depressed again after all the hard work
they’ve done in the past. So often I hear, “I’m tired of fighting it. I can’t
go on fighting.” No wonder some depressed persons feel like giving up
entirely. Depression is frustrating. The only way forward is to go slowly
and to take small steps. Frustrating indeed.
A mental-physical illness
There are many reasons to think of depression as a physical illness. De-
pression can stem partly from genetic (inherited) vulnerability; it is as-
sociated with changes in patterns of brain functioning; it is often
accompanied by physical ill health; and it is responsive to medications
and electroconvulsive therapy.
But we should not lose sight of the mental aspects of depression. I
view it this way: Psychological and social stress leads to physiological
stress, which can lead to persistent adverse changes in brain function-
ing. This may be a hard concept to grasp. The meaning of events in your
life-recent or remote-can produce physiological stress that alters the
way your brain functions.
The sequence is this: Stressful events take on psychological meaning
which generates brain changes. For example, losing your job (event)
may lead you to fear that you can no longer support your children
(meaning), which in turn leads to persistent stress-related changes in
your brain and the rest of your body. Often the stressful psychological
meanings revolve around two broad themes: loss and failure. For exam-
ple, you may feel alone, unlovable, inadequate, worthless, and so forth.
Thus low self-esteem plays an important role in translating stressful
events into depression. Also our ability to think (negatively) about
long-range implications plays a significant role in the meaning of stress-
ful events. You may think, for example, “I’ll never be able to find an-
other job,” or “I’ll never have a good relationship,” or “Things will
never change.”
Fortunately, the mind-brain relationship goes both ways. Positive
psychological and behavioral changes can help reverse the changes in
brain functioning. The interplay of physiology and psychology is the
reason that the best treatment of depression often involves a combina-
tion of medication (or electroconvulsive therapy) and psychotherapy.
Time to recover
Here’s more about the “rock” of depression: You may think you should
be able to recover quickly. You may hold a stereotype of others who
take antidepressant medication for a few weeks and then feel well. You
may conclude it’s your personal failure that accounts for your pro-
longed depression. Consider this: A large group of individuals who
sought treatment for depression at major medical centers—often after
several months of depression—typically took a number of months to re-
cover. Of course, some recovered sooner, and others recovered later,
but 5 months was in the middle range. That is, half of the persons in the
Course of recovery
The course of an illness refers to its progression over time—a fever has a
waxing and waning course when it gets worse, then better, then worse
again. The course of depression can be very complex. And there are
many different subtypes of depression, with major depression being the
prototype. The diagnostic criteria for major depression include five or
more of the following symptoms, most of the day every day, for at least
2 weeks: depressed mood, diminished interest or pleasure, appetite or
weight changes, sleep disturbance, motor agitation or retardation, fa-
tigue or loss of energy, feelings of worthlessness and guilt, problems
with concentration and decisions, and thoughts of death or suicide. Al-
though there are different patterns of symptoms associated with depres-
sion, and there are certainly many different developmental pathways to
depression, it is helpful to think of depression as one illness that varies
in severity and duration. Four levels of severity can be distinguished:
The length of time to response and remission can vary greatly from one
person to another. To repeat, about half of the persons admitted to a
major medical center for treatment of major depression achieved recov-
ery (2 months of remission) after 5 months of treatment. Major depres-
sion entails 2 weeks of symptoms, and chronic major depression is
defined as symptoms of major depression for 2 years. Dysthymia is dis-
tinguished from major depression by both severity (milder) and dura-
tion (more persistent). That is, a diagnosis of dysthymia requires at least
2 years of depression at a level milder than major depression. The com-
bination of dysthymia and major depression is sometimes called “dou-
ble depression.” A person with dysthymia who becomes more severely
depressed (major depressive episode) may “recover” to the level of pre-
vious dysthymia or, ideally, may fully recover to a state of wellness.
There are many factors that indicate risk for relapse and recurrence.
The single most powerful predictor of relapse and recurrence is a con-
tinuing state of active illness, that is, some level of ongoing depres-
sion—even if it is mild. Hence ongoing dysthymia and even one or two
“subthreshold” symptoms entail increased risk for major depression.
This should make intuitive sense: If you’re already partway there, it is
easier to return to being extremely depressed.
Another powerful predictor of recurrence is a history of multiple de-
pressive episodes. Other predictors of relapse are similar to those that
predict a slow time to recovery: ongoing life stress, low social support,
and the presence of other psychiatric problems such as substance abuse,
anxiety, and personality disturbance. Personality disturbance involves
recurrent problems in interpersonal relationships. Such relationship
problems contribute to depression in part because they are likely to be a
major source of stress. And interpersonal stress is among the most com-
mon forms of stress.
The fact that some ongoing depression is the greatest risk factor for
relapse has a clear implication: You should aim for full recovery, restor-
ing your mood “back to normal.” And the longer you can remain in this
recovered state, the less the risk of recurrence. Also, to the extent that
you can get help early and can work to minimize further episodes, your
chances of staying well increase. Continuing in treatment is one way to
maximize your chances. Unfortunately, an extremely common pattern
is this: A person in a major depressive episode takes medication, feels
Here’s another idea about an adaptive response gone awry. You be-
come depressed when you’ve lost something—an important relation-
ship or a valued goal. When the situation appears hopeless, continuing
to strive toward a goal would be counterproductive. You need to let go.
Depression forces you to disengage, to let go of the unattainable goal.
We are taught, I think, that giving up is a bad thing. But too much per-
sistence is also a bad thing; it can be futile and wear you out. I think giv-
ing up is an underrated coping strategy. The challenge is to know when
to give up. But giving up is emotionally difficult. Depression forces your
hand. It forces you to stop striving and to let go. But it goes too far. You
may lose interest in all goals. The approach-pleasure system shuts
down.
Here’s another idea that best fits the relationships between depres-
sion and trauma. Think of depression as a response to oppres-
sion—feeling overpowered by someone. Think of the animals in the
traumatic learned helplessness experiments, overpowered by the situa-
tion set up by the psychologists. When subjected to inescapable shock,
many of the animals would just lie down and give up, showing signs of
depression. When the experimenter made it possible for them to escape,
the animals remained depressed and didn’t learn. These animals were
traumatized—oppressed and depressed. Fear does you no good when
you are overpowered; you cannot escape the oppression. And when you
are overpowered, fighting back in anger may only get you hurt worse.
Giving up and submitting may be the most self-protective thing you can
do. Depression takes over and forces you to submit. It protects you
from getting into more danger. But it goes too far. You may give up on
everything, and you may remain depressed even when you’re no longer
in danger or when you’re in a position to do something to overcome the
oppression.
All these theories about the adaptive functions of depression sug-
gest that depression has a purpose, but it is overdone. Depression
could be considered a signal that you are feeling overwhelmed and
overpowered. You cannot reach your goals, and somehow you must
do something differently. But you keep pushing yourself, to no avail.
Depression stops you in your tracks. Viewed as a signal, depression
should be heeded. Being able to tolerate depression is an important
strength. To tolerate it means to allow yourself to feel it and under-
stand where it’s coming from. It’s a signal that your goals and strate-
gies (or your stressful lifestyle) need to be reconsidered.
Unfortunately, depression goes beyond being a signal to being a seri-
ous illness that impairs your ability to cope. When you recover from
depression, you can learn to heed the signals of mild depression to pre-
vent yourself from sliding into deeper depression.
Although it sometimes may seem like it, depression does not come out
of nowhere. Severe and persistent depression often has a long history.
We can usefully think of depression as one illness, but there are many
different developmental pathways into it. I think about the develop-
ment of depression simply as involving a combination of biological vul-
nerability and a pileup of stress over the lifetime. I also believe that
attachment relationships play a significant role in the creation of stress
and in coping with stress.
Biological vulnerability
Depression has a genetic basis. What does this mean? Genes carry the
instructions for creating the molecular building blocks of cells, organs,
and bodies. Individual differences stem from a unique combination of
genes in interaction with a unique environment over the course of devel-
opment. Throughout life, genetic instructions control the production of
molecules that control the functioning of neurons in the brain, includ-
ing manufacture of neurotransmitters and their receptors. Neurons are
highly social creatures, continually changing their connections and pat-
terns of communication. All this communication turns genes on and
off, altering the production of molecules and the functioning of the
brain. Taking medications alters the biochemical environment of the
neurons, and they respond by changing their behavior, thereby return-
ing patterns of brain functioning to normal.
We do not know just what genes contribute to vulnerability to de-
pression, although the hunt is on. Probably many genes, each with small
effects, are involved. But we do know from family studies that a vulner-
ability to depression can be inherited. Keep in mind that heredity is not
destiny. Your genetic makeup alone will not lead to depression. But
your genetic makeup can contribute to a higher risk for depression
given exposure to environmental stress.
Genetic vulnerability and stress interact in complex ways to produce
depression. We know that stress is a major culprit in the development of
depression. But not all stress is bad. On the contrary, stress is an inevita-
ble part of living, and early exposure to challenging stress can be benefi-
cial. Effectively coping with stress leads to resilience and hardiness. On
the other hand, repeated overwhelming stress can undermine resilience
and hardiness, leading to vulnerability to depression later on in the face
of stress. We know that stressful life events play a major role in bringing
on depressive episodes. Examples of common stressful events contrib-
uting to depression are marital problems, divorce, losing a job, serious
illness, being assaulted, and so forth. But not everyone who experiences
Attachment trauma
Many persons who struggle with severe and persistent depression have
a history of extreme stress—trauma. A landmark study on the social or-
igins of depression in women conducted in London by George Brown
and colleagues showed that those who experienced major depression
typically had experienced either a severe life event (e.g., death of a loved
one, divorce, loss of a job) or an ongoing difficulty (e.g., marital con-
flict, caring for a very difficult child) before the onset of depression. Yet
many women who encountered such stressors did not suffer a major de-
pression. What made the difference? Later research discovered that
many of those with less resilience had a history of childhood
trauma—abuse and neglect. Could it be that those who had a history of
childhood trauma were more vulnerable to later stress? Yes, for both
psychological and physiological reasons.
The essence of trauma is feeling extremely frightened and alone,
without support. There are many sorts of trauma, ranging from torna-
does to assaults, and trauma can involve either a single event or re-
peated events. Trauma can befall a person in childhood or adulthood or
both. In my view, trauma in attachment relationships (e.g., abuse and
neglect by caregivers or romantic partners) is especially likely to have
severe consequences, depression among them. Attention has rightly fo-
cused on abuse (sexual, physical, and emotional), but it is also impor-
tant to recognize the impact of isolation and neglect, both of which are
associated with depression. Trauma in attachment relationships in
childhood is especially worrisome because it affects the development of
the child. For example, childhood trauma can contribute to developing
depression early in life, often in adolescence. Childhood depression can
We know that habits, by their very nature, are hard to change. De-
pression is being stuck, going in circles, spinning your wheels, or just
shutting down. It’s hard to pull out of depression, and it’s hard to stay
out of depression. But, as much trouble as it causes when it’s not func-
tioning up to par, we should be grateful for our prefrontal cortex. We
are always capable of new learning.
Assuming you are struggling with severe depression, you will need to
work on many fronts. There is no simple solution. And each front in-
volves catch-22s. This section breaks down these catch-22s into several
domains: biological, behavioral, cognitive, and interpersonal—all of
which capture different treatment approaches to depression.
In general, the only way I can think of to cope with the catch-22s is to
set modest goals and to try to remain content with small steps of prog-
ress. Of course, this will be difficult. Depression is a painful state; it
causes all manner of difficulty in your life; and you want to get out of it
as soon as possible. But you cannot do it quickly. Setting your goals too
high leads to disillusionment and more self-criticism. Here’s another
catch-22: Slow progress toward goals is depressing. So the challenge is
to set your sights on modest short-term goals, keeping long-term goals
in the background. Small successes are one way out.
Physical health
You may not be able to work on all fronts at the same time. I think the
best place to start is with physical health. Certainly, you should have a
thorough physical evaluation not only to investigate general medical
conditions that might contribute to depression (e.g., thyroid disease)
but also to treat any general medical condition that may be undermin-
ing your health and strength in other ways. A simple example: How are
you going to cope with depression when you have the flu?
Sleeping and eating well should be at the top of the list. For many per-
sons, a key part of the treatment for depression is medication, which is
intended to help with your physical condition (sleep, appetite, energy
level) as well as your mental condition. But any actions you can take to
improve your mood and decrease your anxiety will also help your phys-
ical health. Sleep should be a very high priority, and antidepressants as
well as sleeping medications may be helpful in that regard. Good sleep
hygiene is also important (e.g., not using stimulants late in the day,
making an effort to settle down before going to bed, adhering to a regu-
lar sleep schedule).
Activity level
A good next step after attending to your physical health is to work on
your activity level. Again, a catch-22: If you’re depressed, you don’t
have the energy or motivation to do much of anything. Small steps
here. We know that exercise (e.g., aerobic exercise) is a good antide-
pressant. It’s also a good antianxiety activity. But it’s not likely you’ll
have the energy to do vigorous exercise if you’re severely depressed.
Getting out of bed and getting bathed and dressed can feel like climb-
ing a mountain. Once you can get yourself going, holding to a regular
schedule or structure—a plan for activity throughout the day—will
be important. When you’re getting well, you might consider exercise.
You’ll need to work up to it. Mind you, we’re not talking about en-
joying activity here. Rather, the goal is just trying to get yourself go-
ing.
Seeking pleasure
After activity, I’d focus on attempting to experience more pleasure. You
can force yourself to take action to a certain degree, but you cannot
force yourself to feel pleasure. You can only provide yourself with the
opportunity to feel pleasure. Because anxiety interferes with pleasure,
learning and practicing relaxation techniques can be of some help in
this regard. Imagery, meditation, biofeedback, and deep breathing are
examples.
One aspect of behavior therapy for depression entails listing all activ-
ities that have provided pleasure for you in the past and making a plan
for doing them in a regular, systematic way. This is a good idea, and it’s
worth putting time and effort into it. But remember that the core of de-
pression is low positive emotion. The pleasure circuits aren’t working
properly. They need to be jump-started. I think you can jump-start them
with activity. All you can do is put yourself in situations where you
might experience some pleasure.
At first, you’re more likely to feel a spark of interest, involvement, or
absorption in something rather than outright excitement, pleasure, or
playful joy. Thus you might start by just trying to get yourself engaged
in something that will take your mind off your suffering for a bit. You
might try to be more aware of moments of interest or slight glimmers of
pleasure. They won’t last—you’re depressed. But they might increase in
frequency and duration over time. Some persons who’ve been de-
pressed hit on something they enjoy. Then, understandably, they do it
in an addictive way. They overdose on the activity, it becomes stressful,
and the pleasure wears out. Go slowly with pleasure; it’s best not to try
to force it.
Thinking flexibly
After pleasure I’d tackle thinking. This is getting into the complicated
territory of cognitive therapy. Cognitive therapy is proven to be effec-
tive in treating depression. Yet some patients are put off by cognitive
therapy because of a misunderstanding. Aaron Beck, who developed
cognitive therapy for depression, cautioned that cognitive therapy
should not be confused with the power of positive thinking. He empha-
sized that cognitive therapy does not mean thinking positively but
rather thinking realistically. I would also emphasize that changing your
pattern of thinking is difficult. It’s hard work, and it takes a long time. If
you think it’s supposed to be easy, you will feel like a failure at cognitive
therapy, and you’ll only feel more depressed. This is not how cognitive
therapy should work!
I look at it this way: Your mood has your thinking by the tail. If
you’re depressed, you cannot stop thinking negatively. Even if you’re
not depressed, you cannot stop thinking negatively! Everyone has nega-
tive thoughts and, if you’re depressed, you have tons of them. They’re
automatic, like reflexes—thought reflexes. You cannot stop your re-
flexes. And, in my view, many of the negative thoughts in depression are
not unrealistic or distorted. Bad things have happened, and they have
bad implications. That’s one reason why you’re depressed! These auto-
matic reactions lower your mood, and then you have negative thoughts.
The challenge is to avoid getting stuck in these negative thoughts, rumi-
nating about them, and then going down further into the pit of severe
depression.
What you can do, if you’re not extremely depressed, is get a grip on
your negative thinking and create more flexibility in your mind. The
most important step you can take is to learn to question your negative
thinking. You reflexively have the negative thought (“I really screwed
up”), but then you can be aware of it and question it, taking another
point of view on it (“To err is human”). There’s nothing wrong with
having negative thoughts, but it is important to focus your negative
thinking. The problem is not negative thinking per se but rather global
negative thinking (“I’m a completely worthless human being, always
have been, and always will be”). After thinking “I’m a total screw-up,”
you might think, “I screwed up this one thing today, not everything to-
day.” Then you might even offset this by thinking about something else
you did well. The goal is not to switch from focusing on the half-empty
to the half-full view of the glass, but rather to be able to see that the glass
can be both half-empty and half-full. You fail, and you succeed. Better
focused negative thinking also can lead to problem solving. If you fail a
test and think, “I’m a total loser,” you are stuck. If you think instead, “I
should have studied harder,” you have a direction.
Thus you can be bummed out, think negative thoughts, and yet pull
yourself out of the spiral rather than getting stuck in rumination. Easier
said than done, especially when you’re depressed. This is extremely
hard work. I think it’s very hard to control your thinking, and most pa-
tients I talk with agree. It’s easier when you’re feeling calm, and it’s
harder when you’re feeling upset or depressed. Controlling your think-
ing is a difficult skill that can only be increased in increments across the
lifetime. The catch-22: You could be better at it if you weren’t de-
pressed. In keeping with this idea, a recent approach begins cognitive
therapy after recovery from depression with the goal of preventing re-
lapse and recurrence.
ing the piano. You’d not want to be thrown into giving a concert if
you’d not practiced. Or think about needing to run from danger. You’d
not want to be out of shape when the bear is charging. Few of us are
concert pianists or Olympic runners. But long practice can lead to some
degree of skill, which can be employed when the going gets tough.
Relationships
I’ve saved the most complex for last. There is a thicket of catch-22s in
the interpersonal domain of depression. If it’s difficult to control your
own mind, how difficult must it be to keep your relationships in bal-
ance? There’s a big catch-22 here: Often problems in relation-
ships—conflicts, losses, and breakups—play a major role in triggering
depression. Often enough, a history of traumatic relationships—abuse
and neglect—plays a role in the history of depression. Thus relationship
problems are often major contributing causes to depression. The catch
is this: Supportive, caring relationships are an important aspect of heal-
ing from depression—and preventing relapse into depression. We have
a problem when the cause of depression is also the remedy.
If you’re depressed, you’ve doubtlessly been encouraged to seek sup-
port. You may have heard, perhaps countless times, “Don’t isolate
yourself from others.” If you’ve been hurt by others, you are likely to
want to withdraw. Even without a history of being hurt by others, de-
pression prompts you to withdraw. Recall the idea of pleasure circuits
in the brain, which are somewhat shut down in depression. Commonly,
pleasure is associated with contact with others. Those who are more
cheerful tend to be more sociable; they’re extraverts. Contact with
other persons is a major source of pleasure for many persons. When
you’re depressed, you don’t find activities interesting and pleasurable,
and this includes socializing with others. You might want to crawl into
bed and turn your face to the wall.
Also, when you’re depressed, contact with others can be very stress-
ful. Depression tends to be contagious, and you have a sense that others
don’t want to be exposed to it. They withdraw from you. In addition,
when you’re depressed, you are inactive. You may not talk much, make
much eye contact, smile, or show much facial expression. You may not
show an interest in others, but rather you may be quite self-preoccu-
pied. You don’t make a very good conversational partner. Or you have
to force yourself, and it wears you out to do so. Thus others may not
find it easy to interact with you, and you may encounter either subtle or
blatant rejection. Rejection fuels your wish to withdraw as well as your
feelings of inadequacy and negative thinking.
Here’s yet another problem. You’re encouraged to reach out for sup-
port when you’re distressed. It’s quite likely that you’ve done so. But
the helper cares about you, the more frustrated and anxious the helper
will become.
When the helper’s support fails to be effective, there are two ways the
helper can go wrong. I think the natural inclination is to push harder
and to become critical (at worst, “If you’d just get up off your...”). After
criticism also fails, the helper may be inclined to give up and withdraw.
This leaves the depressed person being alternately criticized and aban-
doned, both of which fuel depression.
At best, those who want to support you are in a difficult situation.
They too are at risk for becoming distressed, frustrated, and depressed.
It is a lot to ask of you when you are depressed, but it is likely that you
will need to coach your helpers, letting them know what’s more helpful
and what’s less helpful. This is not easy for you to do, and it may not be
easy for the helper to hear. To feel criticized for not helping in just the
right way also can be very discouraging and frustrating. But often help-
ers need reinforcement—they need to hear that they are being helpful.
And they may need to learn that just being there, without doing any-
thing or fixing anything, is what’s most helpful. Mainly, you will bene-
fit from understanding and a compassionate attitude—precisely the
attitude that is important to try to cultivate in your own mind, toward
yourself.
Integrated treatment
Several forms of treatment—medication, electroconvulsive therapy, be-
havior therapy, cognitive therapy, and interpersonal therapy—have
been demonstrated to be effective in promoting recovery from depres-
sion as well as in relapse prevention. Collectively, all these treatments
address all the domains of catch-22s discussed here.
Antidepressant medication is often employed as a first-line treatment
of depression, although psychotherapy also can be a viable alternative
to medication. Many research studies show that combining psychother-
apy and medication is the optimal approach. Psychotherapy can be em-
ployed to facilitate recovery when medication is only partially effective,
and psychotherapy can be employed along with medication to decrease
the risk of relapse or recurrence. Keep in mind that one of the most com-
mon problems in treating depression is giving up on treatment prema-
turely. Continuing on medication well after recovery and taking great
care in collaboration with your doctor about discontinuing medication
is essential to preventing recurrence. You may not need to remain in
psychotherapy continuously, but you might find it helpful to return to
therapy periodically for support during times of extra stress. Getting
the level of care you need when you need it is just what you would do
with other physical illnesses.
Appendix
Depression as illness
Following the model of interpersonal psychotherapy (Klerman,
Weissman, Rounsaville, & Chevron, 1984), we present depression as a
Development of depression
Depression is best understood from a developmental perspective
(Hammen, 1992) that provides a balanced view of neurobiological
and psychosocial contributions. The evidence for a genetic contribu-
tion is well established (Hyman & Moldin, 2001), although the route
from genes to behavior is far more tortuous than is typically appreci-
ated (Elman et al., 1996). Patients can be educated about the
diathesis-stress model in which genetic vulnerability increases risk
for depression in response to stressful life events (Kendler, Thornton,
& Gardner, 2001). Notably, genetic factors (e.g., by influencing
temperament and personality) also contribute to risk for exposure to
stressful life events that precipitate depression (Kendler, Karkowski,
& Prescott, 1999) as well as to level of social support that serves a
protective function (Kendler, 1997). A wide range of general medical
conditions are also significant in the etiology of depression (Ameri-
can Psychiatric Association, 2000). And depression itself can be
viewed as a dysregulated high-stress state associated with wide-
spread adverse physiological effects (Dubovsky, 1997; Sapolsky,
1994).
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