In any analysis of depression and anxiety these conditions can be viewed from several different perspectives (8). Here for pedagogical reasons we are restricting our analysis to four different perspectives. The selection of any of the four has a number of implications in terms of the recommended type of treatment, treatment goals and the ways in which it is determined whether or not these goals have been achieved. However, regardless of which perspective is employed, a reduction in the severity of the patient's symptoms must surely be one of the treatment goals. Depending on which perspective is chosen, other treatment goals can be used side by side with a reduction in the patient's symptoms.
1. Depression and anxiety are caused by dysfunctional biochemical processes. This perspective is often called the "biological perspective''. At least some of the people who apply this perspective think genetic factors play an important role in determining an individual's vulnerability. A doctor who has this perspective often recommends pharmacological treatment for patients who fulfil the criteria for depression or anxiety disorders. For example, by taking antidepressant drugs the patient's biochemical processes are expected to become more functional and the corresponding symptoms of depression are expected to decrease. Among psychiatrists such a biological perspective seems common (9).
Representatives of the biological perspective often measure results by the level of the dysfunctional symptoms present (see perspective 4 below). However, treatment results can be measured in two different ways. One way is to say that the treatment can be viewed as effective if the symptoms, as measured by a symptom index, have been reduced by 50% or more. The other way is to argue that it is an effective therapy if the symptoms when treated and when measured by an accepted psychiatric scale (in practice the DSM, i.e. "The Diagnostic and Statistical Manual of Mental Disorders'' published by the American Psychiatric Association, or the ICD, i.e. "International Classification of Diseases'') no longer fulfil the criteria for the psychiatric condition. This means that a treatment can be effective according to the first meaning but not according to the second meaning or vice versa.
The biological perspective encourages the belief that a rather short-term evaluation, e.g. over six to eight weeks, gives valuable information. In such a brief time span it is possible to determine if the biochemical processes of the individual can be returned to near normal levels. Why we have so few long-term evaluations of psychotropic drugs is partly determined by an acceptance of this perspective. Another reason is the costs in terms of money and time of long-term evaluations.
2. Depression and anxiety are caused by an interaction between an individual's internal cognitive system and the demands of the indivi dual's situation. This can be called the "interactional perspective". Those who adhere to the interactional perspective tend to believe that the outcome cannot be evaluated by the presence (or absence) of the symptoms alone. Also, according to this view, we have to wait longer than a few months to see if the individual has recovered or not.
The interactional perspective can be further divided into situational orientation and, secondly, cognitive and emotional orientation. Those who subscribe to situational orientation think that environmental factors, e.g. mourning, are the main causes of a patient's symptoms. A positive attitude towards situational orientation seems to be common among GPs (9,10). Also, the general public tends to regard depression and anxiety as being caused by environmental or situational factors, e.g. conflict at work, disputes in the family setting (11). Counselling about practical and daily matters is a treatment often recommended by those who have this situational orientation. We can expect a GP with such a perspective to encourage discussions about what has happened and about what can be done to help the patient to recover. Also, the recommended treatment often combines a situational orientation with the energy perspective discussed below. For example, to get a person in a state of mild depression to take part in social and other activities is often seen by the general public as beneficial to the individual concerned (11-13).
Supporters of the situational orientation approach tend when evaluating treatment to combine an analysis of the dysfunctional symptom levels with a consideration of how the patient has improved socially. According to this perspective a relapse is seen as much in terms of social functioning as in terms of symptoms.
The second type of interactional perspective can be called "cognitive and emotional orientation'' and includes identity factors as causes of depression and anxiety. Here the therapist's interest is focused on the patient's inner world and not the outer world as in the situational orientation. Those who have a cognitive and an emotional orientation regard the patient's dysfunctional cognitive system as the main explanation for the disorder. Here, cognitive therapy is often a recommended treatment strategy for depressive or anxiety disorders, e.g. (14).
The psychodynamic framework focuses upon the interaction between the individual and her environment and how the personality develops during childhood. However, both the psychodynamic and the cognitive frameworks include cognitive and emotional factors. Also, both frameworks take into account unconscious influences upon these cognitive and emotional factors (15).
For those who have a cognitive and emotional orientation treatment is often assessed by combining an analysis of the dysfunctional symptoms with a study of how the selection of psychological coping strategies has improved during the treatment period.
People who have an interactional perspective do not necessarily see symptoms like agitation or sadness as something bad. Instead the symptoms may help the individual to reconstruct her cognitions and develop a better fit between her cognitions and her environment. The symptoms could be a starting point for "personal growth" (16).
In the interactional perspective the relationship between the therapist and the patient is very important. A "therapeutic alliance" including psychological warmth, trust and empathy will increase the patient's willingness to search for new cognitions and new relationships with her environment (17,18). Through an empathic understanding the therapist can achieve a relationship of trust with her patient. However, if the patient really wants a psychotropic and suffers severe depression or anxiety, perhaps even of an episodic nature, a GP might prescribe a psychotropic as a way of building up a trusting relationship.
3. Depression and anxiety are disorders where the individual can no longer control her psychic energy. From this perspective loss of capacity to control one's own energy leads to affective symptoms because energy control is necessary to achieve desired emotional states such as satisfaction and happiness. In the phenomenological tradition these states are called "flows" and are characterized by individual, goal-directed activities where the individual loses her sense of time, sees the activity as of value in itself and becomes free from worries (8,19). According to Csikszentmihalyi (19), a state of "flow" is when: "Your mind isn't wandering, you are not thinking of something else; you are totally involved with what you are doing. Your energy is flowing very smoothly. You feel relaxed, comfortable and energetic''.
However, when a person is depressed there are often inner turmoils and crises which occupy her internal world. To be free of anxiety and depression it is necessary, according to Csikszentmihalyi, to make oneself free of the demands of the situation in order to experience flow.
This perspective may be called "the flow perspective'' and it is possible to combine it with perspectives 1 and 2 above. The reason is that this perspective "explains" depression and on a lower level is much closer to the symptoms experienced. This means an incapacity to experience flow can be caused both by biochemical and cognitive factors.
In a therapy based on a flow perspective the patient has to be helped to break her negative thought patterns, inner turmoils and cognitive incon-gruences. This will help her to focus her awareness on what she regards as an interesting task. This can be expected to facilitate the achievement of flow.
4. Depression and anxiety are a number of specified dysfunctional symptoms analysed in a defined way. This is the perspective of the DSM scheme that is often recommended by medics. The alternative ICD scheme of psychiatric classification is more often used in Europe and is based on the same perspective. In the definitions of major depression and generalized anxiety the causal factors are disregarded in these schemes. The reason for this is that the application of causal factors diminishes the reliability when diagnosing a specific patient as having a psychiatric condition. If a diagnostician has to base her diagnosis on assumed causal factors we would have much lower reliability than in a diagnostic system, where the causal factors are ignored. By basing the diagnostic system on symptoms whose reliability is accepted, a comparatively high level of reliability in the ultimate diagnosis can be achieved.
However, to our knowledge GPs avoid the DSM and the ICD systems because of their complexity. Another reason for their lack of popularity among GPs is that they need aetiological models when assessing, treating and communicating with patients suffering from depression and anxiety (see discussion below).
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