Depression And Stress

We can make a start at integration by focusing on that well-known but tricky concept, stress. The simple reason for this is that there is little doubt now that major depression is a state of chronic stress as measured by subjective reports, life events (Morriss & Morriss, 2000), physiological indicators of autonomic nervous system hyperarousal (Toates, 1995), and overactivity of the hypothalamic-pituitary-adrenal (HPA) system, which results in high cortisol levels, called hypercortisolaemia (Levitan et al., 2000; McGuade & Young, 2000; Nemeroff, 1998; Raadsheer et al., 1994). Importantly, hypercortisolaemia has many detrimental effects on the immune system (Maes, 1995), and various internal organs and brain areas (Sapolsky, 1996,2000), and by feedback interactions itdowngrades 5-HT, an important neurotransmitter in mood regulation (McGuade & Young, 2000). There is good evidence that even in the less severe depression of dysthymia there are significant physiological disturbances of functioning (as in the HPA system, immune systems, and neurotransmit-ters) (Griffiths et al., 2000). Although there are a variety of regulators of the HPA system (Nemeroff, 1996) that may operate differently in different types of depression (Posener et al., 2000), so important is the HPA system in depression that new therapeutic efforts are being targeted at hypercortisolaemia (McGuade & Young, 2000).

In a large epidemiological study, Kessler and Magee (1993) found that childhood adversities are related to both onset and recurrent episodes of depression. In a follow-up of 121 student women, Hammen et al. (2000) found that women with a history of childhood adversity needed less stress to trigger depression than those without childhood adversity. Andrews (1998) has shown that chronic depression in women is linked to childhood sexual abuse. Hence, aversive early relationships can skew development towards anxiety, depression, suspiciousness, shame sensitivity, non-affiliation (poor help-seeking), aggressiveness, and social wariness or avoidance. It is possible that part of the difficulty for people abused or neglected as children is that, via a process of repeated activation of stress and the defensive behaviours (such as protest-despair or submissive inhibition to an aggressive parent), there is a sensitisation and kindling of the key neurocircuitry of these defensive strategies, similar to that for fear (Rosen & Schulkin, 1998). Additionally, other strategies, e.g. for more relaxed and secure social behaviour, are understimulated or underdeveloped (Perry et al., 1995). In effect, the person approaches his/her environment needing to spot harms quickly, go on the defensive, and minimise harms (Gilbert, 1995). Genetic effects can make some individuals especially sensitive to these social contexts (Suomi, 1997).

Thus, the physiological states of depression are real enough (just as they are for heart disease and other diseases), but this does not mean they 'cause depression' on their own, for they could be consequences of other factors (such as high-stress environments). Rather, we should constantly think about interactions and that depression emerges or takes the patterns it does from interactions of processes (Gilbert, 2001a). In a way, this is like cake making—where, although we can try to identify the ingredients of a cake, it is difficult to separate out the ingredients once it is cooked—and it is the cooking that makes the cake. However, there are some ingredients that seem important.

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