Diverse models of depression have been proposed and debated. Much of the confusion that exists in this area is because of disputes about the nature of mental illness. The confusion is compounded by the fact that core depressive symptoms, such as sadness and feelings of hopelessness and helplessness, are also found in medical diseases, as reactions to stress and as part of normal mood.
Medical model: The medical model considers psychiatric disorders as diseases, supposes brain pathology, documents signs and symptoms and recommends treatments. The disease halo reserved for the more severe forms of depression is also conferred on people with depressive symptoms secondary to stress and poor coping skills. The focus for diagnosis of depression centres on symptom counts without assessment of context, stress and coping skills. The provision of support by health professionals mandates the need for medical models, labels and treatments to justify their input. Insurance reimbursement also necessitates the use of disease labels. Consequently, psychiatric culture now tends to view all depression and distress through the disease/medical lens.
Perceptions in primary care: Patients visit general practitioners (GPs) when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms. Bereavement, marital discord, inability to cope at work and financial problems also lead people to seek help from their doctors. In this context, the major challenge is to distinguish between distress and depression. Depression in patients encountered by GPs is often viewed as a result of personal and social stress, lifestyle choices or a product of habitual maladaptive patterns of behaviour. Consequently, GPs often subscribe to psychological and social models of depression.
Population perspectives: Social adversity is often seen as a cause of depression by the general population. Under such circumstances, people are reluctant to consult their GPs, counseling is the preferred treatment and antidepressants are viewed with suspicion by patients as they are considered addictive. Religious models are also popular. The general population seems to simultaneously hold multiple (and often contradictory) models of illness. They seek diverse treatments from assorted centres offering healing. The protracted course of depression secondary to chronic stress, lifestyle and poor coping results in people shopping for varied solutions.
Pharmaceutical approach: The pharmaceutical industry has espoused the cause of the medical model for depression. It has aided and abetted the medicalisation of personal and social distress to its advantage. Sponsoring educational activities and professional psychiatric and user meetings and conferences have helped shape medical and patient opinions. While pharmaceutical companies play a major role in the development and testing of new treatments firmly rooted in the medical model, in actual practice theirs is a culture driven by profit rather than by science.
Competing cultures: The medical model is defended by the powerful biological psychiatry movement within the specialty of psychiatry and by the pharmaceutical industry. But the other models and cultures of depression emphasising psychological and social issues are equally valid in the contexts of primary care and the community, but lack the academic clout and financial resources to present their points of view. The different ‘cultures of depression’ and the pressures from these divergent perspectives need to be acknowledged.
The issues which need to be re-examined include: (i) the heterogeneity of the concept of depression, (ii) the (in)adequacy of a single label of depression, relying solely on symptoms counts, to describe the diverse human context of distress, (iii) the need for clinical formulations which clearly state the context, personality factors, presence or absence of acute and chronic stress and extent of coping, (iv) the fact that antidepressant medication is not the solution to mild and moderate depression and should be reserved for severe forms of the condition, (v) re-emphasising the need to manage stress and alter coping strategies, using psychological treatment for people with such presentations, (vi) de-emphasising medicalisation of personal and social distress and, (vii) focusing on other underlying causes of human misery including poverty, unmet needs and lack of rights.
Clinical presentations: The syndrome of depression includes depressed mood, loss of pleasure in almost all activities, poor concentration, fatigue, medically unexplained symptoms, insomnia, guilt and suicidal ideation. Three categories of depression can be identified from a clinical and treatment point of view. The first, called adjustment disorder, is a normal reaction to acute and severe stress in people with a past record of good coping. The magnitude of the stress would temporarily destabilise many people with good coping strategies. By definition, the condition is time-limited and people usually settle back to normal lives within a few weeks or months. There is an absence of a family history of depression or suicide. The self-limiting nature of the condition means that support is all that is usually required and results in good outcome.
The second type of depression is characterised by its chronic nature (called dysthymia). Stressors, usually mild and multiple, precipitate, exacerbate and maintain the symptoms. The onset of such depression is usually in early adult life and such people usually have a long history of depressive symptoms. Their moods fluctuate and are usually responsive to changes in the environment. They also have a history of maladjustment and poor coping in response to past stress. The mainstay of treatment is psychological interventions which focus on improved coping, changes in personality, attitude, philosophy and life style.
The third category is called melancholia. In addition to the basic syndrome of depression, symptoms of melancholia include a pervasive depressed mood with minimal response to environmental change, global insomnia, early morning awakening with low mood worse in the mornings, significant loss of weight and restlessness, agitation or slowed movements. Melancholia usually occurs later in life and there may be a family history of similar depression or suicide. Such presentations may be also part of a bipolar disorder (manic depression), which has extreme mood swings, or may be due to medical, neurological and endocrine disease. The treatment of choice is antidepressant medication, management of the underlying medical causes and hospitalisation.
Management: Clinicians and psychiatrists managing patients with depression should be able to hold multiple models of depression. They should be able to appreciate the diverse cultures of depression and choose appropriate treatment strategies. Clinically, there is a need to look beyond symptoms and explore personality, situational difficulties and coping strategies in order to comprehensively evaluate biological vulnerability, personality factors and stress. The treatment package for such presentations should include psychological support, general stress reduction strategies (for example, yoga, meditation, physical exercise, leisure, hobbies) and problem-solving techniques (for example, cognitive therapy) for subjects presenting with ‘depression’. Antidepressant medication should be reserved for the severe forms of depression with hospitalisation and electroconvulsive therapy for those with high risk of harm to themselves and to others. People can present with a mixture of clinical presentations requiring a combination of approaches. A psychosocial formulation of the clinical presentation, background and context will put issues in perspective.
The progressive medicalisation of distress has lowered thresholds for the tolerance of mild symptoms and for seeking medical attention for such complaints. Patients visit physicians when they are disturbed or distressed. Grief at loss, frustration at failure, the apathy of disillusionment, the demoralisation of long suffering and the cynical outlook of pessimism usually resolve spontaneously without specific psychiatric intervention. Distress and emotions should not be mistaken for pathology; fear and apprehension should not be labeled as anxiety, or sadness as depression.
The failure of individual models and cultures to explain all aspects of depression seen in diverse settings has led to the development and use of multiple models, which argue for the need to accept the many perceptions as partial truths. These models should be viewed as complementary rather than competitive, with some being more valid in a specific context than others. Patients present to physicians with their illnesses while doctors diagnose and manage disease concepts. The failure to bridge the gap between disease and illness and healing and cure is a major cause for the contemporary confusion in the diagnosis and management of depression. There is a need for more pragmatic approaches which move beyond the specific models of depression and narrow ‘cultural’ perspectives.
( K.S. Jacob is Professor of Psychiatry at the Christian Medical College, Vellore.)