Running Head: MAJOR DEPRESSIVE DISORDER

Major Depressive Disorder Sarah Dobey AT513/Psychopathology November 15th, 2011 David Katz, Ph.D.

MAJOR DEPRESSIVE DISORDER Abstract

The purpose of this paper is to explore how Major Depressive Disorder is expressed in terms of symptomology, examine comorbidity, potential causes, current treatments, and the effect exercise, in the form of yoga, may have on symptom reduction. Thinking more holistically, physical symptoms of depression are considered along with the potential biochemical and physiological causes. Current somatic and psychological treatments for Major Depressive Disorder are briefly discussed considering benefits and shortcomings. Lastly yoga, derived from Ayurveda, Indias traditional system of natural medicine, is presented as a potential form of treatment. A review of the supportive research displays the potential effect of yoga in combating symptoms within psychological disorders. Keywords: Major Depressive Disorder, yoga, depression, mood disorders

MAJOR DEPRESSIVE DISORDER Major Depressive Disorder It is estimated by the World Health Organization (WHO, 2011) that 121 million people worldwide are affected by depression. According to Layous,

Chancellor, Lyubomirsky, Wang, and Doraiswamy (2011), 70% of depression cases, even within affluent nations, do not receive the recommended level of treatment or do not receive any treatment. An all-encompassing melancholic mood, debilitating functioning, characterizes this disorder. Depression is thought to have several contributing factors, though there is still much uncertainty to causation. The incapacitating symptoms of Major Depressive Disorder (MDD) have a largely based physical component. There are also high comorbidity rates with MDD; it is not uncommon for other mental disorders to co-occur. Common treatment for Major Depressive Disorder is often medication, psychotherapy, electroconvulsive therapy, or transcranial magnetic stimulation. Current research suggests the efficacy of physical activity such as yoga in the reduction of MDD symptoms. Symptoms of Major Depression Disorder and Comorbidity Major Depression, initially identified as melancholia by Hippocrates in the fourth century B. C., is considered a mood disorder resulting in evident feelings of loneliness and sadness in diagnosed individuals (Beck & Alford, 2009). These feelings of sadness, as noted in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) (American Psychiatric Association [APA], 2000), are accompanied by a negative self-concept and often feelings of worthlessness or guilt, hopelessness, loss of interest in usual activities and often apathy. Depression,

MAJOR DEPRESSIVE DISORDER an umbrella term encompasses Major Depressive Disorder, Dysthymia, Psychotic Depression, Postpartum Depression, and Seasonal Affective Disorder (APA, 2000). Depression is also an immensely draining physical illness. Those who suffer from depression may feel exhausted, finding they are sleeping constantly and have

trouble getting up in the morning. Some individuals, in contrast, may have difficulty falling asleep or experience a decrease in appetite. It is not uncommon for individuals with depression to feel achy. Other symptoms consist of difficulty concentrating, suicidal thoughts, and general psychomotor retardation. Symptoms contributing to a diagnosis of MDD must display a shift in behavior, persist for a minimum of two weeks, and cause significant impairment to social and occupational aspects of life (APA, 2000). Depression has high comorbidity rates, often occurring in individuals diagnosed with Substance-Related Disorders, Anxiety Disorders, ObsessiveCompulsive Disorder, Anorexia Nervosa, Bulimia Nervosa, and Borderline Personality Disorder (APA, 2000). Most often Depression and Anxiety are interrelated; almost half of individuals who meet criteria for MDD also meet criteria for an anxiety disorder (Forbes, et al., 2008). This level of comorbidity presents a challenge for practitioners; the greater the level of comorbidity increases the number of symptoms. This, in turn, presents more symptoms to be treated, thus creating a poor prognosis for the individual. High comorbidity also relates to lower levels of functioning and longer treatments with likelihood of relapse (Forbes et al., 2008).

MAJOR DEPRESSIVE DISORDER Causes of Depression Due to the complexity of psychological disorders there are a multitude of contributing factors to mood disorders such as MDD. Many times depression may indicate an underlying health condition such as hypothyroidism or other diseases.

Often though in the case of MDD, there is an interaction between genetic disposition and environment. A major issue in diagnosing MDD is there are many underlying causes beyond the conventional biomedical perspective that may contribute to depression. In addition, to our genetic makeup, there are biochemical and physiological causes of depression. For example, diet, stress, exercise, sleep, environmental toxins, and hormonal imbalances have an impact on our health and susceptibility to depression. Factors in our diet such as nutritional deficiencies, malabsorption, allergens, and food sensitivities, alcoholism, drug abuse and excess stimulants such sugar and caffeine can have a huge impact on mood, thus affecting MDD (Strohecker, 1999). Often individuals with depression may self medicate with food and substances. Unfortunately, these actions can have profound physiological effects on the body, perhaps agitating the depression. The physical dimensions of depression are not always taken into account although they can play a large role into contributing to the pathology. Various aspects in our environment right down to the elements of our diet impact our health and in turn our susceptibility to illness. For example, aspartame an artificial sweetener has shown to decrease levels of serotonin in the brain; low levels of serotonin have been correlated to depression (Humphries, Pretorius, & Naud,

MAJOR DEPRESSIVE DISORDER 2008). Iron deficiency and hypoglycemia are just two other examples of how our body and mood can be altered by our diet (Strohecker, 1999). By taking into account multiple potential factors for mood disorders mental health prevention is more likely to be successful. Current treatments For those with MDD the most common forms of treatment involve

psychotherapy such as cognitive behavioral therapy or interpersonal psychotherapy and somatic treatments such as antidepressant medication, electroconvulsive therapy, or transcranial magnetic stimulation (Layous, Chancellor, Lyubomirsky, Wang, & Doraiswamy; Seo, MacPherson, & Young, 2010). Typically the first method of treatment is in the form of medication, more specifically selective serotonin reuptake inhibitors (SSRIs). Various antidepressants have been used for treating depression since the 50s (Seo, MacPherson & Young, 2010). Antidepressant medications came about accidentally when researchers discovered the euphoric effects on tuberculosis patients receiving a drug by the name of isoniazid (Ramachandraih, Subramanyam, Bar, Baeker & Yeragani, 2011). This discovery led to the development of more modern SSRIs and also shifted the focus of depression from a psychodynamic approach to a more biological basis. A more commonly known antidepressant Prozac was the first of its kind to correct the chemical imbalance of one of the suspect neurotransmitters (Ratey, 2008). Fifty percent of patients, however, show an inadequate response to antidepressant treatment (Seo, MacPherson, & Young, 2010). Unfortunately, gains

MAJOR DEPRESSIVE DISORDER in treatment are often plagued with a range of side effects, most commonly sexual dysfunction. It has been estimated 50 percent of individuals on SSRIs complain of some type of sexual side affect (Ratey, 2008). SSRIs also may increase the risk of suicidal thoughts and actions in children and adolescents. Even with treatments deemed successful, drug therapy has been criticized for failing to provide people with tools they need to prevent relapse. Electroconvulsive therapy (ECT), one of the oldest forms of psychiatric treatment, is still seen as an effective treatment for Bipolar Disorder, Major Depressive Disorder, and Catatonia (Sienaert, 2011). Typically electroconvulsive therapy is seen as a last resort with severe cases that have not responded to medications or psychotherapy. More than 80 percent of all electroconvulsive therapy treatments are performed on individuals with Major Depressive Episode (Sienaert, 2011). Though the interworking of electroconvulsive therapy is still unclear, the basic theory is grand mal seizures are induced through prescribed electrical currents. When ECT was first prescribed as a form of treatment there

were some evident risks involved such as muscle tears, prolonged memory loss and bone fractures. Since 1938, when ECT was first introduced, methods have been altered to decrease the amount of potential side effects (Sienaert, 2011). Still with alterations, possible side effects may entail cognitive impairment such as confusion, memory loss, and disorientation (Forbes et al., 2008). Successful treatment methods for depression extend beyond the somatic realm, from which they began, of antidepressants and electroconvulsive shock, now also incorporating psychosocial therapies such as cognitive-behavioral therapy

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(CBT). Cognitive behavioral therapy (which began as cognitive therapy) grew out of Arron Becks identification of cognitive distortions through his work with depressed patients (Miller, 2011). Beck (1979) refers to cognitive therapy, as a direct, timelimited approach to treat a variety of disorders based on the assumption that affect and behavior are largely determining factors. Cognitive therapy eventually renamed CBT; takes into account both cognitions and behavior, aiming to increase patients awareness of both factors within themselves. Antidepressants, electroconvulsive therapy and cognitive behavioral therapy are only three of the numerous methods available to treat depression. There are many other somatic and psychotherapies available. Though, part of the difficulty with treatment is in how differently depression manifests itself within individuals. There is a wide spectrum of symptoms; what depression may look like in one person may be very different than the next - which in turn alters treatment efficacy. Like any mental health disorder, the best method of treatment should be individualized to fit the needs of that client. Another crucial approach in the treatment of depression is taking into account the array of symptoms an individual has rather than viewing depression as merely physiological (treating it with antidepressants) or psychological (treatment through psychotherapy). Yoga Ayurveda and a holistic model The current treatment methods for depression discussed in the former section have numerous shortcomings. The expense of previously examined treatments may deter many clients along with the potential side effects from anti-

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depressants or ECT. The availability to seek out forms of psychotherapy as well may be difficult for those living in more rural areas. Depression has many interacting factors that can result in a wide variety of symptoms. Many individuals who suffer from depression may seek alternative forms of treatment, perhaps methods using a holistic approach. According Liebler and Moss (2009), 40 percent of Americans regularly seek care outside the Western medical model. Many forms of alternative and expressive therapies are gaining popularity. The benefits of yoga, meditation, and exercise are receiving an increased recognition as potential forms of treatment in the western world. Many ancient traditional health care methods have long embraced holistic health taking a more integrative and multidisciplinary approach to treatments. Since depression cannot be explained by one cause, difficulty comes with trying to treat it as such. How depression is manifested in an individual varies often impacting all aspects of ones life. Ayurveda, native to the Vedic civilization, is the worlds oldest system of natural medicine practiced continually for over 5,000 years (Strohecker, 1999). Ayurveda meaning, science of life has only recently been introduced to the Western world in the form of therapeutic interventions such as aromatherapy, sound therapy, massage therapy, chakra therapy, meditation, mental health through diet and yoga therapy (Liebler & Moss, 2009). Yoga, a component of Ayurveda, is designed to integrate the mind, body, and spirit. The classical most comprehensive form of yoga, Raja yoga, is comprised of

MAJOR DEPRESSIVE DISORDER eight aspects (Strohecker, 1999). The eight aspects, which are metaphorically

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depicted as limbs, yoga as the tree, are: yama (universal ethics), niyama (individual ethics), asana (physical exercises and postures), pranayama (breathing exercises), pratyahara (minimizing ones need), dharana (concentration), dyana (meditation) and Samadhi (bliss) (Ross & Thomas, 2010). Currently more than six million Americans practice yoga, motivated by the prospect of wellness and specific health conditions (Strohecker, 1999). Current research on yoga as a form of treatment is limited. Support, however, is increasing due to evidence suggesting yoga is responsible for physical and mental health improvements of individuals through down-regulation of the hypothalamicpituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS) (Ross & Thomas, 2010, p. 3). Ross and Thomas (2010) have created a visual schematic summarizing the impact of stress on both the hypothalamicpituitaryadrenal axis and the sympathetic nervous system. In their review of the literature, Ross and Thomas (2010) have found numerous studies documenting the effect of yoga on these two complexes. Yoga is noted to have positive effect on the body by decreasing levels of salivary cortisol, plasma, heart rate, and blood pressure. Other studies in the review by Ross and Thomas (2010) found yoga to actually reverse the negative impact of stress (p. 4) on the immune system. Additional studies also indicate immediate psychological effects such as decreased anxiety, (and) increased feelings of emotional, social, and spiritual well being (Ross & Thomas, 2010). Liebler and Moss (2009) indicate research involving asana and mediation reveal reductions in pain, fatigue and sleep disturbances all

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common symptoms of depression. Alternative studies examining the direct effects of asana among those with depression indicate reduction in depression, tension, and anger (Forbes et al., 2008). Yoga has also resulted in changing levels of gammaaminobutyric acid (GABA). The reduction of the GABA neurotransmitter is noted to reduce symptoms for individuals with anxiety and depression (Forbes et al., 2008). Despite supportive evidence from current research, which suggests a reduction in depression symptoms, questions are raised regarding what specific components of yoga create these physical and emotional effects. Because the eight limbs of yoga address mind, body and spirit the entire body system, it seems logical individuals with MDD would find some type of relief from yoga. The diverse manifestations of depression within individuals seem to coincide with the varied focus of yoga as mentioned previously. There are many distinct styles of yoga, appearing very different from one another, each a potential reducer of stress. Some forms of yoga are more meditative and relaxing, others may use props such as blocks or straps, and some more vigorous even involving intense heat. Questions remain as to which forms of yoga are better suited for particular manifestations of mental health disorders such as, MDD, what dosage is most effective, if it is more effective as a stand alone treatment or provided in conjunction with other treatments, and if certain populations benefit more from yoga than others. Supportive evidence for yoga exploration is needed to elaborate how best individuals can reap these benefits; only research can provide these answers. Conclusion

MAJOR DEPRESSIVE DISORDER The complexity of psychological disorders raises questions. The cause of

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depression is viewed as multifaceted - an interplay of environmental, psychological, emotional, social, and genetic contributions. Without the exact understanding of depression, current treatments may fail short and only addressing minimal aspects depression. The high comorbidity rates of MDD also bring a challenge to treatment methods along with the array of possible symptoms a client may present. The traditional ancient model of Ayurveda examines human beings more deeply than the western medical model, taking a holistic view of health. Yoga, an important aspect of Ayurveda, has been effective in elevating mood, and over all wellbeing (Forbes, et al., 2008). Yoga, in contrast to other forms of treatment, considers the mind-body connection without the negative side effects of other common treatment approaches. The very basis of yoga as a physical treatment may help combat the physical and psychological symptoms of depression. In the end, though, treatment is always client based. With more research and the advancement of neurotechnology depression can be better understood, treatments improved upon.

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Ramachandraih, C. T., Subramanyam, N., Bar, K. J., Baker, G., & Yeragani, V. K. (2011). Antidepressants: From MAOIs to SSRIs and more. Indian Journal of Psychiatry, 53(2), 180-182. Ratey, J. J., Hagerman E. (2008). Spark: The revolutionary new science of exercise and the brain. New York, NY: Hachette Book Group Inc. Ross, A. & Thomas, S. (2010). The health benefits of yoga and exercise: A review of comparison studies. The Journal of Alternative and Complementary Medicine. 16(1), 3-12 Seo, R. J., MacPherson, H., & Young, A. H. (2010). Atypical antipsychotics and other therapeutic options for treatment of resistant major depressive disorder. Pharmaceuticals, 3(12), 3522-3542. doi:10.3390/ph3123522. Sienaert, P. (2011). What we have learned about electroconvulsive therapy and its relevance for the practising psychiatrist. Canadian Journal of Psychiatry.Revue Canadienne De Psychiatrie, 56(1), 5-12. Strohecker, N. S. (1999). Natural healing for depression: Solutions from the worlds greatest health traditions and practitioners. New York, NY: The Berkley Publishing Group.