The holistic nature of depression: risk factors, consequences, and treatment options.

McKinney, Beth ; Maxey, Heather

Introduction

Depression has been identified as a common and incapacitating mental health disorder. For people suffering from depression, multiple depressive episodes are common and potentially chronic (Hollon, Thase, & Markowitz, 2002), which can reduce one's ability to function in daily life (World Health Organization, 2012). According to the DSM-IV, a person can be diagnosed as having suffered a major depressive episode if they experience "a period of two weeks or longer during which there is either depressed mood or loss of interest or pleasure and at least four other symptoms that reflect a change in functioning" (Substance Abuse and Mental Health Services Administration, 2006, Online). Such symptoms may include feelings of guilt or low self-esteem, changes in sleep or eating habits, fatigue, and an inability to focus (World Health Organization, 2012). Approximately 1/3 of all people will suffer from depression at least once in their lives (Gillam, 2004), with an annual prevalence of major depression affecting 15 million adults in the United States (National Alliance on Mental Illness, 2009).

While depression can and does affect all people, it is more common among certain subpopulations. Depression is twice as common among women as men, with 1 in 8 women being affected by depression at least once in their lives (Mayo Clinic, 2010a). Depression is also most common in people between the ages of 45 and 64 (Centers for Disease Control & Prevention, 2012; World Health Organization, 2012), but is the leading cause of disability for people between the ages of 15 and 44 (Mental Health America, 2012). However, the World Health Organization estimates that "by the year 2020 depression is predicted to reach 2nd place in the ranking of DAYLs [disability adjusted years of life] calculated for all ages, both sexes" (World Health Organization, 2012, On-line). Because depression affects so many people and interferes with a person's ability to function in everyday life it is important to examine this mental health disorder from a holistic perspective. The purpose of this paper is to address the biopsychosocial nature of depression with regard to risk factors, consequences, and treatment options.

Risk Factors for Depression

A variety of biopsychosocial factors have been shown to increase a person's risk for depression (Goldstein & Rosselli, 2003; Karren, Smith, Hafen, & Jenkins, 2010). The development of depression is often augmented by an interaction among these factors (Karren et al., 2010). Biological risk factors for depression include, but are not limited to, genetic influences and inadequate neurotransmitter levels (Goldstein & Rosselli, 2003; Karren et al., 2010). Psychosocial risk factors for depression are frequently associated with stressful life events (Hollon et al., 2002; Karren et al., 2010) and inadequate social support (Gencoz & Ozlale, 2004; Jou & Fukada, 2002; Karren et al., 2010).

Biological Risk Factors for Depression

Research has shown that people can inherit susceptibility toward depression. Such an inheritance, however, does not necessarily mean that these people will become depressed. While genetic inheritance contributes to the development of depression, the presence of other biopsychosocial risk factors interact to determine whether or not an individual becomes depressed. Nonetheless, having siblings or parents who are depressed increases a person's likelihood of developing depression as much as three-fold (Price, 2010). According to Sandler (2007), "individuals with a family history were more likely to have an earlier first onset, more episodes and symptoms, and greater severity of condition compared to those without a family history" (p. 57).

Researchers are conducting studies aimed at determining the specific gene or set of genes that will predict susceptibility toward depression. The 5-HTT gene, which plays a role in the regulation of serotonin, has been identified as a potential genetic risk factor for depression (Waldholz, 2011). This gene may be associated with research findings revealing that genetic factors can cause a lack of neurotransmitters, which has been indicated as an additional risk factor for depression (Karren et al., 2010). While this specific gene may play a role in the development of depression, most researchers believe it is "more likely that a number of genes acting together may cause a person to become vulnerable to depression" (Price, 2010, On-line).

As indicated, depression often results in people with inadequate levels of certain neurotransmitters, including serotonin and dopamine (Hollon et al., 2002; Karren et al., 2010). These neurotransmitters serve to stimulate the pleasure center in the brain and when they are lacking, pleasure is no longer experienced and depression can occur. Deficient serotonin levels can also cause endorphin levels to decrease. A lack of endorphins makes the body more susceptible to pain and less capable of experiencing pleasure, thus compounding the likelihood of developing depression.

Psychosocial Risk Factors for Depression

Stressful life events consist of anything that "cause[s] ... the disruption of normal life balance, loss, conflict, or trauma" (Karren, Hafen, Smith, Frandsen, 2002, p. 246). When stressful life events are experienced on a regular basis the brain can become conditioned to inadequately produce and regulate neurotransmitters such as serotonin. As suggested, the occurrence of such inadequate levels has been shown to increase the risk for depression. In addition to influencing the biological risk factors for depression, stressful life events may also contribute to the development of depression even further by influencing psychosocial risk factors for depression. As stressful life events become more intense depression has a tendency to increase. The impact of stressful life events is compounded when the event negatively influences one's self-esteem. Perception of stressful life events can also contribute to depression. People who dwell on stressful situations and view them as problematic are more likely to experience depression (Karren et al., 2002).

People who lack social support are more likely to perceive life events as stressful and to allow such events to deteriorate their self-esteem, which has been shown to lead to depression (Karren et al., 2002). According to Gencoz and Ozlale (2004), "depressed people tend to have less social support, report less contact with friends, have fewer friends nearby who can help, and have less satisfaction with friends and relatives" (p. 449). Receiving less support than requested has also been associated with depression (Jou & Fukada, 2002). Therefore, the connection between depression and social support depends on the availability of social relationships as well as the level of support such relationships provide.

Consequences of Depression

Not only is the risk for developing depression increased by biopsychosocial factors, but it has also been shown to result in various biopsychosocial health consequences. Biological consequences of depression include impaired immune function, increased risk for physical health conditions, and premature death. Psychosocial consequences of depression include inadequate social support as well as an increased risk for suicide.

Biological Consequences of Depression

Impaired immune function is one of the main biological consequences of depression. The continuous stress response often found within people suffering from depression causes excess amounts of cortisol to be produced, which inhibits immune function. Depression also has a negative effect on various cells within the immune system, such as a reduction in white blood cell response, natural killer cell activity, and helper cell production (Karren et al., 2002). As a result, the immune system is unable to protect the body, making depressed people more susceptible to various health problems, including an increased occurrence of autoimmune diseases. In addition to increasing the risk for new health problems due to decreased immune function, depression can also have a negative effect on pre-existing health problems. Depressed people are likely to suffer more intensely as a result of pre-existing health problems, "becom[ing] sicker, need[ing] more medication, and spend[ing] more days in the hospital" (Karren et al., 2002, p. 260). This intense suffering may be caused by the fact that pain and disability are also more common among people with depression. The pain associated with depression results from a decrease in endorphin levels, which inhibits the body's ability to alleviate pain. As previously mentioned, a lack of endorphins is caused by low serotonin levels, which leads to depression (Karren et al., 2002).

The impaired immune function and resulting health problems associated with depression can lead to a four-fold increase in mortality. In depressed people, the following health problems are more likely to result in death: stroke, coronary artery disease, myocardial infarction, certain cancers, and diabetes. Another factor contributing to death from depression is a lack of self-care (Karren et al., 2002), evident in the fact that depressed people "tend to do much more poorly on self-treatment and self-monitoring of chronic illness" (Karren et al., 2002, p. 269) and "may delay longer than others in seeking medical attention following onset of signs and symptoms" (Perskey, KempthorneRawson, & Shekelle, 1987, p. 447).

Psychosocial Consequences of Depression

Feelings of helplessness and hopelessness (Goldstein & Rosselli, 2003; Karren et al., 2002) associated with depression can cause people to become apathetic about life and the people that make it meaningful. The apathy common in depression leads to symptoms that become manifest when people are not able to function in society (Karren et al., 2002), cease to participate in their usual activities (Hollon et al., 2002; Karren et al., 2002), and withdraw from their friends and family (Hollon et al., 2002). Thus, inadequate social support is one of the main psychosocial consequences of depression. As noted previously, inadequate social support can also increase one's risk for depression, which can further increase isolation and lead to an even greater lack of social support. Consequently, a continuous cycle occurs, making it increasingly difficult for people to overcome depression.

When people lack adequate social support they do not reap the benefit of the stress-buffering effect that such support would provide and are therefore less capable of coping with stressful life events. As noted previously, stressful life events can also increase one's risk for depression (Gencoz & Ozlale, 2004; Jou & Fukada, 2002). People suffering from depression often view life from a pessimistic perspective (Goldstein & Rosselli, 2003; Hollon et al., 2002) believing that "the present conditions and the future possibilities are intolerable" (Karren et al., 2002, p. 246), which can lead to "recurring thoughts that life isn't worth living" (Donatelle, 2012, p. 40). As such, suicide is a significant psychosocial consequence of depression, with approximately 15% of the depressed population committing suicide (Karren et al., 2002). In fact, during 2009 there were more than 36,000 suicides reported in the United States, making suicide the 10 leading causes of death (Kochanek, Xu, Murphy, Minino, & Kung, 2011).

Treatment Options for Depression

Based on the holistic nature of depression it stands to reason that treatment attempts should be approached from a holistic perspective, taking into consideration the biopsychosocial risk factors for and consequences of the disease. In order to be effective, treatment programs must undertake a wide range of treatment options (Hollon et al., 2002; Karren et al., 2002), each directed toward alleviating a specific risk factor for depression (Karren et al., 2002). While the biological, psychological, and social treatments have proven effective in and of themselves, often times combining these treatment regimens can increase the likelihood of positive treatment results (Hollon et al., 2002; Karren et al., 2002). Therefore, combining treatments that address the biological, psychological, and social risk factors for depression may be the most comprehensive and beneficial method for treating depression. One of the most common biologically-based treatment options for depression is the use of anti-depressant medications. Some common psychosocially-based treatment options for depression include cognitive behavioral therapy, stress management, and the development of social support.

Biologically-Based Treatment for Depression

Selective serotonin re-uptake inhibitors (SSRIs) are a commonly prescribed type of anti-depressant medication that work by preventing the reuptake of serotonin (Mayo Clinic, 2010b; Hollon et al., 2002). These anti-depressant medications ensure that serotonin is available in sufficient amounts within the body, thus preventing the lack of serotonin that increases one's risk of developing depression. One advantage associated with antidepressant medication use is that "about half of all patients will respond to a given medication and many of those who do not will respond to some other agent or to a combination of medications" (Hollon et al., 2002, p. 39). In addition to effectively treating moderate to severe depression (Mayo Clinic, 2010b), another advantage specific to SSRIs is that they have fewer side effects than many of the older anti-depressant medications (Mayo Clinic, 2010b; Hollon et al., 2002). However, it is important to also note that the Food and Drug Administration (FDA) has issued warnings that anti-depressant medications can increase the risk of suicidal thoughts and attempts in children, adolescents and young adults (National Institute of Mental Health, 2012).

Psychosocially-Based Treatments for Depression

Cognitive Behavioral Therapy (CBT) attempts to alleviate depression by teaching depressed people how to assess and respond to life events more accurately. The pessimistic outlook common to depressed people often causes them to negatively interpret their life circumstances (Hollon et al., 2002). As such, the cognitive aspect of CBT helps depressed people "become more accurate in [their] self-assessments and perceptions of the world and the future" (Hollon et al., 2002, p. 61). Doing so may, in turn, encourage them to view life events in a less stressful, more optimistic way. In an effort to help people begin living life from this new optimistic perspective, the behavioral aspect of CBT assists people in the development of skills such as problem-solving, relaxation techniques, and social interaction (Massachusetts General Hospital, 2012). The development of such skills can have the added benefit of helping people manage stress, which can further reduce the impact of depression.

More specifically, as people improve their social interactions they enhance their capacity for developing social support. Whether perceived or actual, social support serves to decrease depression (Clara, Cox, Enns, Murray, & Torgrudc, 2003; Hodges, 2002). In an attempt to clarify the mechanisms behind social support's positive influence on depression two explanatory models have been developed. The stress-buffering model states that social support decreases the occurrence of depression only in the presence of severe stress (Jou & Fukada, 2002). For example, aid-related social support, where people believe there are others to whom they can turn in times of need, is associated with the stress-buffering model (Gencoz & Ozlale, 2004; Jou & Fukada, 2002) because it indirectly influences depression by helping people cope with life stressors (Gencoz & Ozlale, 2004). The direct-effect model states that social support decreases the occurrence of depression regardless of the level of stress. For example, appreciation-related social support, where people believe they are capable of helping others, is associated with the direct-effect model (Gencoz & Ozlale, 2004; Jou & Fukada, 2002) because it directly influences depression by enhancing people's self-esteem and sense of worth. Thus, when people are working to alleviate depression it is vital that they not only establish a strong social support network of their own, but that they let others know they are available to offer support as well (Gencoz & Ozlale, 2004).

Conclusion

When depressed people seek treatment the outcomes are extremely positive, with the potential for "80 to 90% of persons who suffer from depression [to] be helped substantially" (Karren et al., 2010, p. 170). However, despite the many effective approaches available to treat depression "more than 75% of depressed individuals receive no specific treatment or inappropriate care" (Hollon et al., 2002, p. 40). Given the variety of biopsychosocial risk factors for and consequences of depression as well as the many effective treatment methods available, a holistic program aimed at prevention and/or control appears to be the most logical approach towards treating depression. Doing so has the potential to improve quality of life, with regard to biopsychosocial health, for individuals suffering from depression, thereby improving their ability to function in everyday life.

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Beth McKinney, PhD, MPH, CHES, Assistant Professor of Health Promotion, School of Health Sciences & Human Performance, Lynchburg College

Heather Maxey, MA, CHES, Instructor of Health Promotion, School of Health Sciences & Human Performance, Lynchburg, VA