This paper has several objectives. First, it seeks to examine Major Depressive Disorder, and the symptoms of and contributors to the disorder. The paper will then provide a summary of the diagnostic criteria as outlined by the DSM 5, as well as the efficacy and side effects of antidepressant medication. Finally, the paper examines Major Depressive Disorder within the South African context including its historical development.
Mood Disorder, Major Depressive Disorder, Symptoms, & Contributors
What is meant by the term “mood disorder”? A mood disorder is broad term that mental health professionals use to describe all types of bipolar and depressive disorders (DeRubeis & Strunk, 2017: 19). These disorders impair an individual’s functioning that often leads to an inability to cope with the stresses of life, and to work productively at work or within communities (often as a result of a marked decrease in energy and concentration) (Ghaemi, 2007: 3). Individuals also report a range of symptoms including feelings of hopelessness, emptiness, excessive guilt, hostility, and elevated aggression. They often struggle with issues relating to low self-esteem, relational issues with intimate partners, work colleagues, and family.
What contributes to mood disorders such as Major Depressive Disorder within an individual? Though medical knowledge has progressed significantly the answer is elusive. Theorists have suggested a number of contributing factors that increase an individual’s vulnerability. For example, there are non-genetic factors resulting from subjective underlying reasons unique to any individual (Levinson & Nichols, 2018). These include experiences of tragic loss (of a child, a family member, or a spouse), stressors resulting from a loss of identity, status, work, and relationships, conflict with significant others (coworkers, family members), as well as various significant abuses (sexual, emotional, and physical).
Biological factors must likewise be acknowledged. On an evolutionary biological perspective mood disorders are evolutionary adaptions (Allen & Badcock, 2006: 815-826) in which a depressed mood could result in one’s turning away from behaviours that are reproductively unsuccessful (Nesse, 2000: 14-20). Furthermore, research from adoption studies strongly suggests that genetics contributes to an individual’s vulnerability to depression (Levinson & Nichols, 2018). Researchers seek to determine the “heritability” of depression in individuals, and it is currently believed that depression is a product of more than one inherited gene as opposed to a single gene. In other words, depression tends to run in families and is passed on.
DSM 5 Diagnostic Criteria For Major Depression Disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders consulted for diagnostic purposes. As of 2013, the DSM-5 has separated mood disorders into two major sections: the “Depressive and Related Disorders” and “Bipolar and Related Disorders,” and as medical research has advanced, some changes have been made to the Depressive Disorders classification by which three new disorders have been added (premenstrual dysphoric disorder, persistent depressive disorder, and disruptive mood dysregulation disorder) (Parker, 2014: 182–190). Nonetheless, for an individual to be diagnosed with Major Depressive Disorder, he or she needs to meet several stipulated DSM 5 diagnostic criteria (Reynolds & Kamphaus, 2013). What follows is a summary:
A. An individual must experience five or more of the following symptoms during a two week period:
1- Depressed mood – Suggested by feelings of hopelessness, emptiness, and sadness that occur in an individual for most part of a day, or nearly every day.
2- Diminishment – A marked diminishment in enjoyment and pleasure in activities during the day for an individual.
3- Weight loss – A significant loss in weight (5% of body weight in a month) during a time in which an individual is not dieting. This is also accompanied with a decrease in appetite nearly every day.
4- Sleep issues – An individual experiences hypersomnia or insomnia nearly every day.
5- Psychomotor agitation – This refers to slowness and feelings of restlessness for an individual.
6- Energy loss – An individual experiences a loss of energy or fatigue nearly every day.
7- Guilt & worthlessness – An individual experiences feelings of guilt and worthlessness nearly every day.
8- Industry – An individual experiences a diminished ability to think clearly nearly every day.
9- Death – An individual experiences recurring thoughts of death (not just the fear of dying) as well as recurring suicidal ideation (without a specific plan). An individual has attempted to commit suicide or has a specific plan for committing suicide.
B. Symptoms must cause significant distress and impairment in important areas of an individual’s functioning.
C. Symptoms are not attributed to any other medical conditions or psychological effects resulting from substances.
D. Symptoms are not better explained by other disorders such as schizophrenia, schizoaffective disorder, schizophreniform disorder, or delusional disorder.
E. The individual has never had a manic episode or a hypomanic episode.
Should the individual meet all the criteria, he or she very likely has Major Depressive Disorder.
Major Depressive Disorder in a South African Context & History
The history of Major Depressive Disorder, as it has developed in South Africa, is difficult to come by. One reason is because the term “Major Depressive Disorder” was first only used in the mid-1970s (Spitzer & Endicott, 1975: 34), and was subsequently only included in the DSM III in 1980 (Philipp, Maier & Delmo, 1991: 258-265). This classification also partook in a specifically American focused context, and it is unknown, according to this paper’s research, how this was first implemented in South Africa at that time.
However, it is possible to track the development of “mood disorders” in South Africa. Private medical health system had its origins shortly after the cessation of WWII, though this overwhelmingly benefitted a primarily middle white class demographic (IPASA, 2002: 19; Ngoma, 2017). Many suffering from both physical traumas and psychological disorders lacked access to basic care not only as a result of racist policies and legislation (from British colonization prior to apartheid) but also due to the impact that the Second Anglo-Boer War (1899-1902) and WWI (1914-1918) had on the quality of medical care and the provision of resources (Mogotlane, 2003: 6-9). Nonetheless, a majority 95% of non-whites had to rely on the public sector for physical and psychological treatment (IPASA, 2002: 33). In a post-apartheid context, those suffering with mood disorders, especially depression within the ranks of the previously disadvantaged, benefitted somewhat as the government sought to implement policies seeking to rectify health inequalities. This was a positive development given that prior to 1997 mood disorders were mostly treated through institutionalization of patients as opposed to psychiatric therapy (Inge et al., 2009: 140). It was far more cost effective to isolate mentally ill individuals.
There are, moreover, worrying statistics for contemporary South Africans living with Major Depressive Disorder seeking treatment. There are only 290 registered psychiatrists in a country home to over 50 million people (this is besides the fact that medical care is incredibly expensive) which results in a physician-population ratio of 1:183 000 (Kale, 1995: 1255). Private mental health care is where the most effective treatment can be found yet, unfortunately, just 20% of all doctors operate in the public sphere serving a majority non-private healthcare demographic (Ataguba, 2010).
Major Depressive Disorder is clearly a significant health issue in South Africa (Tomlinson et al., 2009: 367–373; Janse Van Rensburg, 2015). A 2003-2004 study conducted by SA Stress and Health (SASH) discovered that 33% of South Africans live with a mental health disorder (roughly 17 million people) (SADAG, n.d), although these statistics have not gone unchallenged (Chiumia & van Wyk, 2014). Of the total country’s population, 9.7% live with depression (Health24, 2017). A second concern is that 75% of South Africans living with a mental disorder will not receive medical attention (Lund, Petersen, Kleintjes, & Bhana, 2012: 402), and those who do at government funded institutions are subject to substandard conditions, a severe shortage of health professionals, and noticeable lack of specialized state hospitals (De Kock & Pillay, 2017: 269).
One further observes a significant cultural-racial factor. Certainly depression does not discriminate on the basis of an individual’s race. However, in South Africa there is a noticeable lack of investigation into the cultural factors of depression within black communities (SADAG, n.d.). However, some research has suggested that traditional healing practices in black communities (which includes prayer to ancestors, and visits to diviners and herbalists) are still widely accessed, and as many as 45% of black mental health patients have visited a traditional healer prior to being institutionalized (Fleck, 2011: 326–327). Some believe that demonic possession is behind mental disorders, hence bringing any attention to one’s psychological disorder comes with a fear of social ostracization (Okasha, 2002: 32-35). It is likely that there is an under reporting of mental health disorders within black communities. A number of other contributing factors result in an increased vulnerability to depression, for example, environmental stressors such as overpopulation and unhealthy living conditions, socioeconomic struggles of the likes of unemployment and financial struggles, as well as the memory of recent apartheid policies (SADAG, n.d.).
Major Depressive Disorder & Treatment & Side Effects.
Empirical studies have shown that antidepressant and mood stabilizer medication has proven effective (Arnow & Constantino, 2003: 893-905; Boseley, 2018; Greenlaw, 2018; Nagesh, 2018; PubMed, 2017). Major Depressive Disorder is therefore highly treatable as somewhere between 80 and 90% of people have had a positive response to prescribed medications (SADAG, n.d.). On the same token, without medication symptoms have been observed to severely impact the quality of one’s life often ranging to periods of weeks, months, and even years. It is also believed that the most effective means of treating the disorder is to combine medication with treatment (Cuijpers et al, 2014: 56-67; Sifferlin, 2014). Treatments such as psychotherapy, family therapy, transcranial stimulation, and electroconvulsive therapy have had positive results in treating the disorder.
Though prescribed antidepressants are an effective means of treatment there are indeed limitations and side effects. One limitation is that for health professionals prescribing medication for patients it is often difficult to predict how well a specific medication will assist a specific individual. Often numerous medications need to be tried before an individual can determine which one works. Moreover, the efficacy of antidepressant medication also depends on the severity of the individual’s depression. Antidepressants work most well against chronic and moderate depression and less well against mild depression (NICE, 2009).
Side effects of antidepressant medication are similarly concerning. Statistics differ but they all concede that a certain percentage of people using antidepressants will experience some sort of side effect, some of which will occur shortly after medication is first taken (Cartwright et al. 2016: 1401–1407; Cascade, Kalali, & Kennedy, 2009: 16-18). A number of patients report experiencing headaches, a lowered sex drive, a dry mouth, and feelings of anxiousness. It is, however, difficult to determine whether this is a result of the medication or the depression itself. Differences in side effects are also determined on the type of antidepressant an individual takes whether that be tricyclic or SSRIs (Cascade, Kalali, & Kennedy, 2009: 16-18). The former can result in vision problems, constipation, and trembling whereas the latter can affect sleep, result in dizziness, and nausea. Side effects of tricyclics are generally worse. Age is also a concern. Given that some side effects are dizziness there is the increased risk of falling which for elderly people can put them at risk of breaking bones and experiencing other physical traumas. However, these considered, antidepressants are a necessary mans of treatment and, as explained by John Geddes, an Oxford University professor of epidemiological psychiatry, “an effective tool for depression” (Boseley, 2018).
Cultural Stigma & Misconceptions
Common misconceptions of Major Depressive Disorder suggestive a lack of knowledge on behalf of many concerning mental health issues. Lewis explains that many of these misconceptions are “not based on any scientific fact,” and can in fact worsen conditions by adding “an extra layer of isolation and pain to an already suffering individual” (IOL, 2017). Thus, an awareness of this disorder, and mood disorders in general, is imperative.
One of these is that depression is a sign of mental weakness (Hall, 2018). Some forms of masculinities have also reinforced the social construct that to be “manly” one must be strong, and that strength, both emotional and physical, are sure signs of what it means to be a man (Butler, 1988: 526). Thus, for many men, this paper’s author included, there has been a hesitation to admit struggling with depression given the fear of being perceived as weak. It is true, however, that women are more likely to suffer with depression than men, yet many men still suffer from it. In fact, male suicide rates are at an all time high suggesting that men too experience great underlying emotional pains (Hall, 2014).
There are significant cultural views of the disorder, especially within black communities (Huffington, 2017). Some believe that depression, among other mental disorders, are the result of witchcraft. Thus, traditional healers are commonly accessed although many, having journeyed this path, end up seeking after psychiatric care. However, this has real life implications. A number of individuals within these communities fear social ostracization as a result of the stigma attached (such as the perceived roles of evil spirits, possession, or witchcraft in mental disorders) (Huffington, 2017). Moreover, many make use of traditional practices that are soon deemed therapeutically ineffective and only then subsequently decide to access medical institutions. However, this delay results in the individual experiencing prolonged pain in his or her life as well as in the lives of those around him or her.
A further significant myth pertaining to depression and other mental health disorders is that individuals living with them are dangerous, violent, or unpredictable (SADAG, n.d.). This is a myth often portrayed in popular western entertainment media in which mentally disturbed antagonists are vehicles for evil (Boll, 2015). To the contrary, only 3 to 5% of violent acts, according to The South African Depression & Anxiety Group, are attributable to individuals living with a serious mental illness (SADAG, n.d.). Moreover, those living with a mental disorder are more likely to be victims of violent acts than the general population.
If successful this paper has sought to provide value through its rather brief analysis of Major Depressive Disorder. There remains a significant portion of the public that ought to be educated on the basics of mood disorders given their significant prevalence within South African society. One also hopes that users of antidepressant medication are aware of its limitations, side effects, and efficacy. Historical developments pertaining to the disorder are interesting but not essential for the lived experience of millions today.
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