Biopsychosocial Model And Major Depressive Disorder

To be diagnosed with major depressive disorder (MDD), a person must show at least five emotional, cognitive and/or somatic symptoms for a minimum of two weeks. These symptoms can include depressed mood, anhedonia (diminished interest in activities), difficulty concentrating, recurrent thoughts of death, hypersomnia, significant changes in weight loss or weight gain or loss of energy. However, if the person does not show symptoms of depressed mood and anhedonia then they are not depressed. The biopsychosocial model refers to the biological (genetics, gender, neurotransmitters), psychological (cognitive thinking, feelings) and social (economic status, support networks) factors that contribute to a disorder. The biopsychosocial model allows clinicians to examine and understand the interplay of these three factors and determine the development, maintenance and successful treatment of MDD.

Development

Individuals may have biological predispositions to developing MDD as indicated by family, twin and adoption studies. Twin studies suggest a heritability of 30% to 40% (Hasler, 2013) and Sullivan and colleagues highlight that individuals with MDD are three times more likely to have a first degree relative with the disorder also. Given the high risk of developing MDD, researchers are aiming to find the causative gene, however, it seems that no single or exact gene is responsible, rather it’s a combination of different genes. As a result, preventing the disorder from occurring is highly unlikely due to the heritability of the disorder and the genetic makeup only influences the vulnerability of a person.

Although the genetic vulnerability is critical to the development of depression, the incidence of depression is very low in the absence of social stressors such as economic hardships, lack of support and culture. A study of older Vietnamese adults was conducted to see the correlation between social factors and their mental health (Leggett et al 2012), revealed that 47% of the participants (55 and older) had clinical depression. Amongst these participants, women that were less educated and had material hardships showed higher depressive symptoms. Although, this study cannot be generalised as culture, economy and health support vary from country to country but it reveals how economic hardships, lack of social and emotional support can contribute to MDD.

Moreover, the psychological component examines the way people think, feel, behave and view the world and themselves. It is believed that people with low self-esteem view things pessimistically and therefore are more prone to depression. Empirical studies have also supported the idea that self-esteem predicts depression. This is evident in Steiger et al (2014) 23- year longitudinal study in which demonstrates that individuals who entered adolescents with low self-esteem or whose self-esteem declined during adolescents were more likely to exhibit symptoms of depression in adult years. These findings indicate the importance of cognition in the development and the outcome of depression as well as the need for improvement in self-esteem to reduce the risk.

Maintenance

The biopsychosocial model can assist in determining why MDD continue after it has developed by taking into account biological sex differences, psychological perspectives and social stigma.

A woman’s biological sex differences can contribute to the maintenance of MDD due to the reproductive transitions of premenstrual, postpartum, and perimenopausal phases (Soares and Zitek, 2008) During these phases, women are exposed to different types and levels of hormones that are constantly fluctuating, such as oestrogen, which is thought to increase serotonin (chemicals that boosts mood) becomes lower during perimenopausal, affecting relapse of depressive symptoms. Freeman and colleagues (2010) findings show evidence that women who had a history of depression were nearly five times more likely to have an MDD diagnosis during the transition to menopause. However, the authors make it clear that less than 5% of women reached the menopause stage during the study and thus insufficient for statistical significance. Nevertheless, the study suggests that women transitioning to menopausal are at an increased risk of symptoms relapse as oestrogen levels decrease.

Furthermore, a person’s psychological mechanism such as denial or refusal to accept one’s disorder can hinder their ability to seek help. Consequently, depressive symptoms may worsen the longer the individual delay seeking treatment. Choi and colleagues (2008) have disclosed that 75% of their homebound clients appeared to have depressive symptoms, although a large proportion of these older adults would deny that they were depressed. They suggested the factors that contributed to the refusal of their condition was due to the lack of awareness of the disorder, perceived stigma about mental illness and medical concerns. As a result, ignorance of the disorder can significantly impact on their continuation of the disorder.

Similarly, social stigma can prevent individuals from seeking help and receiving support, which ultimately leads to the ongoing relapse of symptoms. Stigma can involve both the person’s own responses (self- stigma) as well as their perceptions of others' negative responses (perceived stigma). When Barney and colleagues (2006) randomly sampled 1312 Australian adults, they reported that many people felt embarrassed about seeking help from professionals when they were suffering from depression, and believed that other people could hold negative assumptions if they sought help. This demonstrates that both self and perceived stigma can act as a barrier to the initiation of seeking treatment. Thus, it can be concluded that social stigma can potentially affect the maintenance of symptoms due to the negative views people hold.

Successful treatment

The biopsychosocial model allows clinicians to treat MDD through the combination of pharmacological and psychotherapeutic interventions such as antidepressant medications, cognitive behavioural therapy (CBT) and interpersonal therapy.

The biological treatment of MDD is the use of antidepressants medications, which affect neurotransmitters in the brain to bring about change in symptoms. However, according to Vöhringer and Ghaemi, (2011), antidepressants are effective in chronic, moderate or severe MDD. This is evident in Kirsch et al, (2008) findings whereby patients with mild or severe depression were prescribed antidepressants or a placebo. The results have demonstrated that those who took antidepressants showed statistically greater response than placebo. The findings also suggest that antidepressants show significant effects in only severely depressed patients. However, the effect for these patients seems to be due to decreased responsiveness to placebo, rather than increased responsiveness to medication. Nevertheless, it is evident that the more severe depression is, the more effective the treatment will be.

One Psychological treatment involves CBT which entails teaching patients how to think rationally, realistically positively. Many studies have been conducted to show that combining medication and CBT is highly effective. For instance, Brent et al, (2008) found that adolescents who were not responding to initial treatment with just antidepressants responded to a combination of CBT and a switch to another antidepressant. Similarly, Blackburn et al, (1981) compared cognitive therapy, antidepressant drugs and a combination of these two in MDD patients and found the combination treatment to be more superior to drug treatment. Although there are many techniques involved in CBT, which aspect is more effective is unknown, thus Reinecke and colleagues (1998) recommended that detailed descriptions of treatments should be included in future studies. In spite of which technique is more effective, the combination of CBT and antidepressants have proven to be more effective in the long run.

Social factors are also needed to be taken into consideration when treating MDD as they can occur within an interpersonal context and affect relationships. As a result, IPT aims to focus on problems in personal relationships and the skills needed to deal with these. A clinical trial by Mufson and colleagues (1999) found that 18 of 24 patients who received IPT compared with 11 of 24 controlled patients demonstrated a reduction in depressive symptoms and improvement in social functioning and interpersonal problem-solving skills. Despite this, there were limitations in this trial such as the sample size of 48 adolescents who were mostly Latinos, cannot be generalised and therefore further studies must be conducted with other adolescents to confirm generalisability. Also, results could have been a reflection of IPT condition receiving extra three sessions whilst the controlled could only receive one which ultimately hinders the validity of the results. Although the type and size of the sample are relatively small, IPT received substantial empirical support.

Conclusion

In summary, the biopsychosocial model accounts for the development, maintenance and successful treatment by addressing the multifaceted issues facing MDD. The biological perspective reveals that MDD is heritable and thus a person can be vulnerable if there is a family history, however the social component highlights that the disorder will not develop without a social stressor turning the genes ‘on’. The model also accounts for maintenance of MDD by outlining how sex hormones, social stigma and self-perceptions can prevent treatment and contribute to the relapse of symptoms. When treating MDD clinicians also need to consider different types of treatment such as ECT, medications or therapy and determine the best solution according to their patients’ severity and responses to different treatments. By understanding how the biopsychosocial factors independently and interdependently play a role, clinicians can better diagnose and treat their patients

References

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