Category: Major Depressive Disorder

Major depressive disorder (MDD), one of the leading causes of disability worldwide (Thornicroft et al., 2018), is a common psychological condition categorized under mood disorders in the DSM-5. Mood disorders consist of conditions that involve predominant problems with either mood or affect (American Psychiatric Association, 2013). According to the World Health Organisation, the prevalence of MDD in all age categories has increased in recent years, with over 300 million cases reported worldwide (Pan et al., 2018). Affecting one in six adults at some point in their lifetime (Otte et al., 2016) and costing a predicted $147 billion to treat over the next 14 years in the US alone (Chisholm et al., 2016), MDD merits singular discourse regarding its theories and appropriate treatment. In order to achieve a definitive diagnosis of Major Depressive Disorder, the patient must have experienced several of the clinical characteristics of the disorder for a minimum period of 2 weeks. Depressed mood, loss of interest, and feelings of worthlessness are a few examples of the required symptoms (American Psychiatric Association, 2013). The common assumption is that MDD simply occurs as a result of a chemical imbalance within the brain (Deacon & Baird, 2009). Upon reviewing this theory, researchers discovered that MDD actually occurs due to a complex combination of biological, social, and psychological factors (Kupferberg et al., 2016; Beck & Bredemeier, 2016). Even though it is not the primary cause of MDD, a chemical imbalance within the brain as part of the biological approach for MDD does provide some explanation for the symptoms involved with Major Depressive Disorder (Patten, 2015).

In recent years, an accumulating number of studies have looked into and observed the effects of the “serotonin hypothesis”, a distinct dysfunction of serotonin neurotransmission (5-HT) in participants diagnosed with MDD (Domínguez-López et al., 2012). Serotonin, which acts as both a neurotransmitter and a hormone, is crucial to the functioning of several systems and the regulation of mood and anxiety (Carhart-Harris & Nutt, 2017). The hypothesis concerning serotonin neurotransmission states that reduced levels of 5-HT (5-hydroxytryptamine) can increase the likelihood of developing depression (Albert & Benkelfat, 2013). Since the formation of this hypothesis, various studies have confirmed this association between 5-HT and Major Depressive Disorder. Maurer-Spurej et al. (2007) found that patients who were diagnosed with depression displayed significantly low levels of 5-HT in their blood platelets. A more recent study by Ogawa et al. (2014) also found that depression can cause reduced plasma levels of L-tryptophan, which is a precursor for 5-HT.

A monoamine transporter protein known as SERT maintains the regulation of serotonergic neurotransmission by removing variable levels of 5-HT from the surrounding extracellular fluid (Sundaramurthy et al., 2017). The fluctuating levels of 5-HT associated with Major Depressive Disorder are based on the on changes in the promoter region of this gene (Fakhoury, M., 2016). Otherwise known as the serotonin transporter, solute carrier family 6 member 4, or sodium-dependent serotonin transporter, SERT proteins are encoded by the SLC6A4 gene (Manoharan et al., 2016). Neurons in the central nervous system communicate using chemical and electrical messengers. This form of communication is a result of neurotransmission, in this circumstance, serotonergic neurotransmission (Kavalali, 2015). When serotonin (5-HT) is released into the synaptic cleft that exists between a presynaptic and postsynaptic neuron, after generating an action potential in the postsynaptic neuron, SERT allows the re-uptake of 5-HT from this synaptic space in order to be re-used in the presynaptic neuron and thus terminating the serotonin’s effect (Vuorenpää et al., 2016). Due to polymorphisms in the promoter region of SERT, serotonin levels in the brain decrease, leading researchers to discover an association between low serotonin levels and Major Depressive Disorder (Kohen et al., 2013).

Despite the compelling evidence supporting the authenticity of serotonergic transmission in MDD, as well as it being a theory established over 50 years ago (Albert et al., 2012), not all studies in this field have obtained supportive results. Cowen & Browning (2015) proposed that theories linking low serotonin levels with major depressive disorder should no longer be considered tenable, as more recent studies into MDD have found promising results when observing the influence of serotonin on emotional processing. The basis of this explanatory theory for MDD is based on the function and mechanisms of the neurotransmitter, serotonin (5-HT) despite its actual role not yet confirmed after decades of research (Marazziti, 2017). Lacking a formal role for serotonin in cognition may partially be due to the difficulties associated with attempting to identify serotonergic neurons electrophysiologically; current advances in optogenetics may be able to resolve this in the near future (Miyazaki et al., 2014). Another inconsistency within this model for Major Depressive Disorder is the theory of polymorphism when regarding the SERT protein channels. Despite its recent popular use in determining the cause of depression or MDD, this form of polymorphism never received subsequent confirmation (Murthy et al., 2010). According to Booij et al. (2015), this resulted in the formation of inconclusive hypotheses or less conclusive hypotheses concerning how polymorphism actually contributed to this theory.

Even though there is much scepticism regarding this “serotonin hypothesis” model for Major Depressive Disorder, the successful studies that go towards supporting this theory promoted the introduction of selective 5-HT re-uptake inhibitors (SSRIs) as a form of treatment for MDD (Healy, 2015). The introduction of SSRIs into clinical practice represents one of the most significant and successful advances in psychopharmacology as it is still a widely used drug for treating depression and MDD (Stahl, 2017). During normal communication between two nerve cells in the nervous system, after serotonin neurotransmission has occurred, SERT proteins recycle the neurotransmitters back into the presynaptic neuron for future use (Vuorenpää et al., 2016). However, according to the “serotonin hypothesis”, individuals diagnosed with depression or MDD have lower levels of serotonin in their brains (Albert & Benkelfat, 2013). Therefore, any treatment attempting to reverse this would need to have an effect on the regulating mechanisms of 5-HT levels. Such treatments, including SSRIs, are known as reuptake inhibitors (Hicks et al., 2015). SSRIs act as a barricade or a blockage for the SERT protein channels, thus stopping serotonin from reabsorbing back into the presynaptic neurone, therefore forcing the neurotransmitters to remain in the synaptic cleft of the synapse (Holck et al., 2018).

As with the “serotonin hypothesis” for MDD, there is both scrutiny and support for SSRIs as an effective form of treatment. Arroll et al. (2016) reported a significant effect of SSRIs on MDD in primary care when compared to use of a placebo. Cipriani et al. (2018) who conducted a systematic review on several different antidepressants (SSRIs), discovered that all the SSRIs analysed during their research had a significantly larger effect on adults diagnosed with MDD than those who were given a placebo can see similar results in the study. Additionally, during an analysis of several SSRIs based on cost-effectiveness, Sussman et al. (2017) found that brexpiprazole and other specific SSRIs were not only more cost-effective, but also increased response levels and chances of remission after a 6-week period. Based on the success of using SSRIs when treating MDD, this lead to a development of a second generation of SSRIs designed to target specific subtypes of the 5-HT receptors (Stahl, 2008). Unfortunately, not all types of 5-HT dysfunction are detected in patients, which resulted in 50% of cases showing no-response to the drug, and only 30% of patients ever reaching effective remission (Trivedi et al., 2008). Despite some studies finding insignificant results relating to SSRI treatment, Gibbons et al. (2012) observed a significant difference in treatment when comparing fluoxetine and venlafaxine with a placebo drug. In contrast, Fournier et al. (2012) found that SSRIs either had little or no effect on mild or moderate MDD when compared with a placebo, suggesting the SRRIs may only be useful on more severe cases of depression or MDD. However, researchers questioned this study on its statistical basis suggesting that the researchers involved may have underestimated the effect size of various antidepressants (Horder, 2010; Fountoulakis & Möller, 2010).

Biochemical theories, such as the “serotonin hypothesis” have been around for many decades, suggesting that they are probably outdated approaches by now and replacement is necessary. However, supportive studies as recent as the last 12 months found the hypothesis to be fairly accurate.

Research into the effectiveness of SSRIs on treating MDD show both successful and unsuccessful results suggesting that it is an effective form of treatment, but perhaps not for everyone, possibly due to another contributing external or internal factor. With regards for the future of diagnosing and treating MDD, perhaps more advanced research into discovering the link between serotonergic neurotransmitters and MDD will fill in the missing details researchers are currently lacking. Until then, as the “serotonin hypothesis” and SSRI treatments are still producing significant clinical results, it is very likely that they will remain as essential parts of the clinical practice revolved around Major Depressive Disorder.

When I was a sophomore, I was diagnosed with Major Depressive Disorder, but over the past two years, my condition has improved. I believe things like taking drugs, harming myself, and sleeping the day away, would help my depression because when I were doing those things, I felt better. To this day, I am still depressed, but things like exercise, talking about my feelings, and educating myself on my mental illness has helped reduce the severity of my symptoms. Major depressive disorder is a mental health disorder that is characterized by losing interest in activities or a persistently depressive mood which causes a significant impairment in one’s daily life. The best ways major depressive disorder can be managed is by physical activity, seeing a medical professional, and being educated on the condition. These are extremely beneficial ways to reduce the severity of major depressive disorder symptoms. There are millions of people with this condition which puts a burden on society, but these ways of fighting depression can make the world a better place by improving the lives of many.

To begin, physical activity is one of the best ways to manage major depressive disorder. Scientists have hypothesized physical activity to improve the cognitive functions of depressed patients. Mental health disorders, specifically major depressive disorder, crucially impact work productivity. Given that physical activity improves health both physically and mentally, people that regularly exercise are more likely not to suffer from any mental disorders.

“Exercise is a powerful depression fighter for several reasons. Most importantly, it promotes all kinds of changes in the brain, including neural growth, reduced inflammation, and new activity patterns that promote feelings of calm and well-being.” – Lawrence Robinson, Jeanne Segal, Ph.D., and Melinda Smith, M.A.

Exercising regularly helps reduce stress hormones and reduce pain. In addition, physical activity can ease major depressive disorder symptoms, reduce anxiety, improve mood and decrease the chance of a relapse. According to Physical Activity Is A Good Way To Restore Work Productivity Of People With Depression by Aiste Leleikiene, regular exercise mixed with psychopharmacology has been proven to have a positive impact on improving mental status. Psychopharmacology is the scientific study of the way drugs affect the mind and behavior of someone, therefore, the author is expressing that physical activity and medication is the way to go when trying to manage or “cure” major depressive disorder.

Although both methods are beneficial, I personally believe physical activity is just as beneficial as medication but without the side effects. During the time I spent doing sports in high school, I was happier and noticed fewer major depressive disorder symptoms. Being a part of a team and achieving goals lifted my spirit. The most beneficial things sports did for me relating to my condition was distracting me from most of my negative thoughts, boosting my confidence, gaining social interaction, and allowing me to cope in a healthy way.

“Doing 30 minutes or more of exercise a day for three to five days a week may significantly improve depression or anxiety symptoms. But smaller amounts of physical activity — as little as 10 to 15 minutes at a time — may make a difference. It may take less time exercising to improve your mood when you do more-vigorous activities, such as running or bicycling. The mental health benefits of exercise and physical activity may last only if you stick with it over the long term…” – Lawrence Robinson, Jeanne Segal, Ph.D., and Melinda Smith, M.A.

Walking for one hour a day or running for 15 minutes a day has shown to reduce the risk of major depressive disorder by 26%. Although the link between exercise and major depressive disorder is not clear, exercise has been seen to ease the symptoms and help reduce the risk of symptoms returning after they leave. Exercising also releases endorphins which are chemicals in the brain that reduce the perception and interact with receptors. of pain. Like morphine, endorphins trigger positive feelings in the body. Other ways endorphins can be released are eating a favorite food, making music, and having sex.

In addition, seeing a medical professional is just as beneficial as physical activity in an effort to manage major depressive disorder. Seeing a professional includes different types of therapy as well as deciding whether taking medication is the way to go. At the psychological level, cognitive inhibition could be a key method in regulating emotion. According to Towards personalized treatment of depression: A candidate gene approach, cognitive behavior therapy is recommended, but it is not always effective. Another thing that is not always effective is medication; 30% of people that take antidepressants do not respond and 60% respond, but not completely. This leaves only 10% of people being helped with antidepressants. The candidate gene therapy talked about in this article is a technique commonly used to identify genetic risk factors for conditions such as major depressive disorder. In 2008, the National Institute of Mental Health-funded a study. It found that half of the patients that did not feel better after the use of one medication had to take a new one or add a second one to feel better. “Antidepressants work by balancing chemicals in your brain called neurotransmitters that affect mood and emotions. These depression medicines can help improve your mood, help you sleep better, and increase your appetite and concentration.” – Ellen Greenlaw

On the flip side of using medications, there are side effects. Some reported side effects are weight gain, agitation, drowsiness, and headaches. Seeing a medical professional is a good decision to make as well as a very positive step in the direction of improving mental health. Doctors are there to help patients with the current facts and to give them options and next steps. Doctors always have the best interests of their patients in mind and are trained to handle stressful situations. Also, they are aware that there is a unique cultural background of the people they work with, meaning that everyone is different and the same thing will not work for every patient.

Being educated on the mental condition one has, can prevent stigmas. Mental stigmas are labels put on a person or group that sets them apart from society. By talking about mental illness with a medical professional, patients can know the difference between what are facts and what are myths. This can hopefully remove the stigma that has surrounded mental health throughout the years. For example, one myth is that medication is the only way to treat any type of depression. There is more than just one way to deal with this burden such as therapy or physical activity. No one has to go through this alone. As more and more people talk to their doctor about their mental health, it could encourage others to speak to a medical professional. It lets others who suffer from mental disorders know that they are not alone. There are millions that suffer from major depressive disorder which is why the most important reason to speak to a doctor or just someone trustworthy in general is because it can decrease suicide rates. By people not getting the treatment they need, they are at a dangerously high risk for poor mental help which may possibly lead to suicide. A research study done on suicide showed that 90% of successful suicide attempts are committed by those who had symptoms of a mental disorder.

Being educated on major depressive disorder holds many benefits. People who suffer from this need to be able to control it and that is possible by knowing their symptoms and triggers. Everyone with major depressive disorder needs to know their next steps to make sure he/she knows whether they’re making their situation better and not worse. It is important to learn about healthy ways to cope as well as being aware of triggers so that the condition can be better managed. Some triggers are unavoidable (chronic illness), but others are very much avoidable (drinking alcohol). Being educated ties back into seeing a medical professional. After being educated on the condition, one may decide to see a psychiatrist.

“Left untreated, depression can have a significant negative impact on a person’s social, physical, and mental well-being, and place an enormous burden on society. Patients with depression experience a higher incidence of premature death related to cardiovascular disease and are 4.5 times more likely to suffer a myocardial infarction than those without depression. Depression is also very costly. In the United States, the total cost of depression was estimated to be $83.1 billion in 2000 with lost productivity and direct medical costs accounting for $30 billion to $50 billion each year. Health service costs are 50% to 100% greater for depressed patients than for comparable patients without depression primarily because of higher overall medical utilization. Overall, the economic burden of the disease is significant to managed care organizations, with direct medical costs estimated at $3.5 million per 1000 plan members with depression.” – Aron Halfin, MD

At the beginning of my sophomore year, I was sent to a hospital. I spent three days there, after which I was diagnosed with major depressive disorder. Looking back, the cause of my depression started with bullying which I started experiencing bullying in eighth grade, continuing into high school. At the end of my freshman year, I started self-harming and I continued to do so into my sophomore and junior years because the pain in a way felt relieving. In addition to self-harm, I also took pills that were not prescribed to me because I felt hopeless and worthless. I knew there was something wrong with me, but I didn’t know exactly what until I was diagnosed.

Substance use is something that commonly occurs with other mental disorders, but it is not clear whether drugs help something like major depressive disorder occur or whether it is just a symptom.

“Compared with the general population, people addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders, with the reverse also true. In 2015, an estimated 43.4 million (17.9 percent) adults ages 18 and older experienced some form of mental illness (other than a developmental or substance use disorder). Of these, 8.1 million had both a substance use disorder and another mental illness.” – Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health

It is possible for drugs to increase the risk of major depressive disorder and they can also cause paranoia, anxiety, aggression, and hallucinations. Seeing drugs or other substances as the only way to ease depressive symptoms can lead to addiction. ⅓ of major depressive disorder patients have had an alcohol problem which can lead to financial problems by the excessive purchase of these unnecessary items. Physical exercise could be substituted for taking substances because it eases depressive symptoms instead of making them worse.

My social isolation along with poor interpersonal relationships led to me self-harming. This ultimately worsened how I was feeling because I was making things worse instead of better. I isolated myself for so long and that is why I was diagnosed with one of the most severe types of depression. Self-harming can lead to a weaker immune system and great inflammation. Along with permanent scarring, self-harming also put me at risk for a poor self-image and low self-esteem. There are many forms of self-harm such as cutting, burning, starvation, and poisoning. I made a decision to cut myself which could have led to an accidental, inadvertent death. In the UK, self-harm has been named the biggest cause of death from people aged 20-24. From this same age group, 329 people died from a situation that included self-harm (2013). It has been proven that about seven to eight percent of the young people in the UK will self-harm with varying severities.

Over the last two years my symptoms have eased up and I do feel better. I do not self-harm or take drugs anymore. Physical activity, seeing a medical professional, and educating myself are all things that I have done. I have participated in Volleyball, Basketball, and Track and Field. Being a part of a team and having lots of social interaction helped me feel happier, caused me to have less negative thoughts, and gave me something to look forward to. When I was a freshman, my mother noticed I was depressed and she made me see a psychiatrist. For me personally, seeing a medical professional was weird and I did not like it. I knew I needed help, so I talked to close friends whenever I felt like harming myself or felt suicidal. Talking about my feelings always helped me. Educating myself on major depressive disorder was beneficial by helping me identify my triggers. For example, one trigger for me would be excessive social isolation. This is a trigger that is avoidable. Instead of being in my room all day, I can call or text friends or go outside. These three things have helped me and they can help the other millions of people who suffer from major depressive disorder also.

On March 25, 2020, I conducted a personal interview on Brooklyn Perkins who also suffers from major depressive disorder. She has done many strategies that have reportedly eased depressive symptoms. These strategies include volunteering, having a balanced diet, writing in a journal, spending time outdoors, talking to someone about her feelings, being educated on her mental illness, avoiding alcohol and recreational drugs, setting attainable goals, doing enjoyable activities, spending time with loved ones as well as spending time around optimistic people. Things like volunteering and setting goals make her feel good and empowered.

“Talking about my feelings makes me feel weird because I don’t like sharing my feelings with people.” – Brooklyn Perkins

Between physical activity, seeing a medical professional, and being educated on her condition, she only researched. She does not exercise or talk to someone about her feelings. Although she does small things that release endorphins like spending time with her family and spending time around optimistic people, her depressive symptoms could ease more if she participated in physical activity regularly and saw a medical professional. The reasoning behind this is that exercising releases endorphins and a doctor who is trained to deal with mental illnesses like hers can help her differentiate between what are myths and what are facts. A doctor could give her advice on next steps on feeling better. Three strategies she would try in the future are meditation, getting enough sleep, and doing more enjoyable activities. Although these may not be what I see as the best ways to manage major depressive disorder, they may still work. Physical activity, talking about my feelings, and educating myself on my condition is what has helped me get better over the course of years, but just because something works for me does not necessarily mean that it will work for everyone else. It can be argued by critics that these are not the best ways to manage major depressive disorder, but instead are just some good things to consider doing on the road to recovery.

All in all, the best ways major depressive disorder can be managed is by physical activity, seeing a medical professional, and being educated on the condition. These are extremely beneficial ways to reduce the severity of major depression symptoms. There are millions of people with this condition which puts a burden on society, but these ways of fighting depression can make the world a better place by improving the lives of many. I believe these ways are the absolute best ways to manage major depressive disorder mostly because for the past two years I have used these strategies and my symptoms have been eased. Exercising regularly, talking about my feelings, and educating myself on what is going on in my brain and why has also helped my symptoms stay away after I started feeling better.

The focus of this paper is to explore the effect exercise has on North American middle-aged women with major depressive disorder. This topic was chosen because I know many people who suffer from depression and I would like to help find ways to cope with the symptoms and aftermath of this heart-wrenching disease. Finding new ways to help cope with depression may decrease the number of suicides. Depression is a huge driving force for people who commit suicide. This issue remains controversial and has been a source of debate for many years. Several scholars claim that exercise can be used to treat depression, while others claim there is no correlation between the two (Coutinho, 2013). He has also argued that the use of exercise to help treat depression is underestimated and providers should really be looking at the benefits exercise could provide. As of right now, the general treatment for depression is based on pharmacological interventions alone, with a slim emphasis on exercise. However, exercise can help to alleviate symptoms, boost a person’s mood, as well as show improvements in depression, anxiety, and self-concept. The effects of exercise on depression can be long-term, which can help to improve quality of life. Exercise can help release feel-good endorphins, take one’s mind off worries, help gain confidence, get more social interaction, and cope in a healthy way (Mayo Clinic, 2017). It would be nice to know if exercise does, in fact, improve depressive symptoms, as this could potentially save millions of lives. The PICO question researched was, “Among North American middle-aged women, does exercise have an impact on the treatment of major depressive disorder”?

Background

Major depressive disorder (MDD) has been around for many decades now. In fact, depression originated in 400 BC, when it was called melancholia (McKay, 2015). Ever since then, depression has impacted the population locally, nationally, and globally. Globally, 322 million people live with major depressive disorder, with 16.1 million of those people living in America (Anxiety and Depression Association of America, 2018). There were no local statistics on it, but I know many people who suffer from depression in Grand Rapids alone. I have family members who suffer from depression, so this topic is very personal to me. I also know people who have committed suicide due to depression. Even those who are not diagnosed with depression can still live with the effects of it. Depression does not discriminate; It affects people of all ages all around the world. Depression screening is a major aspect in hospitals and clinics. Doing a depression screening on each patient is important because many times depression can go unnoticed by caregivers, or even patients themselves. Even in clinic offices, the nurses ask every single patient about depressive symptoms, even if they are just there for a medication refill. It is important to know if a patient is suffering from depression, so the nurses can help them and prevent them from doing harm to themselves. Treating depression can also help prevent other medical conditions from occurring. Depressive patients may shrug off their physical problems and not even realize it, just to find out they have a serious medical condition later on (CADY Wellness Institute, 2016). By treating depression, nurses can reduce the chances of this happening.

The use of exercise for the treatment of depression is still controversial because several scholars claim that exercise has the same effect as antidepressants, while others say it has no effect on the treatment of depression. There have been countless studies done over the years, some of which will be discussed in this paper. One side of the debate is that exercise can help ease some of the symptoms of depression. The other side of the debate claims there is no correlation between exercise and depression. It is still being looked at today because of how controversial it is. The research gap I ran into with this topic was there were no reliable studies done to evaluate the long-term effectiveness of exercise, as many of the articles focused solely on the short-term effects.

Search Strategies

When I started exploring databases, I selected PubMed first. I typed in “exercise” AND “depression” into the search bar, and it resulted in 15,178 results. I replaced the word “exercise” with “physical activity” and it resulted in 19,996 results. I then typed in “physical activity” OR “depression” and was able to get 874,880 results. When I added the words “North Americans” to my search, the results went down to 158, but the articles were more relevant to my specific population. The next database I chose to look at was ProQuest Central. I first typed in “physical activity” AND “depression” AND “Americans” and was able to obtain 32,746 results. I selected AND instead of OR because I found those articles to be more relevant to my research question. In ProQuest, I replaced “physical activity” with “exercise” and still received 56,721 results. I then went to the American Psychiatric Association and typed in “exercise” AND “depression”. It came up with only five results, one of which actually pertained to my topic. The last database I searched in was ScienceDirect. I searched “depression” AND “exercise” to start out, and I was able to get 115,543 results. The main databases I selected when finding my articles were ProQuest and ScienceDirect because they had the biggest selection of articles to choose from, giving me more options. Many people post about depression on all social media platforms. It is perceived as less severe than other life crises. For example, I had a friend from high school who committed suicide. A couple of my friends and I went on his Twitter page and found one of his tweets that said, “I just need someone to help motivate me”. Another tweet was, “I feel so lonely in this world”. However, many did not take it as serious as it was meant to be, as we just perceived it as him being upset.

Lessons Learned

One lesson I learned when doing my research was the number of results you find are greatly based on the words you use to find the articles. When I used “or”, I had a lot more results that when I used “and”. When I switched “physical activity” to “exercise”, I received less results, but it gave me more of a selection to choose from. As I kept adding more terms specific to my PICO question, the search became more narrow. However, I found articles that were very specific to my question, so it was very helpful.

Another lesson I learned was some of the results only contain an abstract, so they do not have much information with them. I disregarded those articles because they did not provide me with the information I needed. There is an option on ProQuest that allows you to choose “full text”, so I did that to make sure it did not include just abstracts. This allowed me to find quality journal articles with enough information.

A third lesson I learned was that reading the summarized article can be very helpful. I would often feel like I found a good article just by the title, but when I selected it, it did not pertain to my topic. Reading the abstract saved me some time, as I knew right away which articles I could discard.

One last lesson I learned was to not judge an article based on its title. I found a few articles that contained the words “literature review” in the title, but they were not actually literature reviews. I also found an article that consisted of a “qualitative review” in the title, but it was actually a quantitative review. This taught me that it is important to analyze what I am reading to make sure the information is consistent with the title.

State of Evidence

Literature Review

A literature review is a paper written by a scholar, including current knowledge on a particular topic. Sharpe’s literature review, containing 25 articles, examined the correlation between clinical depression and physical activity, specifically focusing on women (Sharpe, 2016). She emphasized how clinical depression is more prevalent in women than men, but the reason is unclear. Insufficient physical activity can be associated with depressive symptoms. Some depressive symptoms including reduced enjoyment levels and interest, decreased mood, fatigue, and reduced energy make it hard to find motivation to engage in physical activity. These barriers should be addressed in the clinical setting, so nurses can help patients work around them by developing an exercise regimen specific to each patient. More research is needed to determine how to encourage women to engage in physical activity.

In another literature review by Anderson and colleagues (2015), 31 articles were reviewed to determine the current findings of the relationship between physical activity and major depressive disorder. Several of the scholars they examined concluded that exercise does improve depressive symptoms and should be utilized. “It has been found that physically active adults have been shown to have 30% lower odds of developing depression” (Anderson, 2015, p.3). This is an alarming statistic that medical professionals should take into consideration when treating their patients.

Meta-analysis

A meta-analysis is a way of combining data from multiple studies by means of a statistical procedure. Coutinho and colleagues (2013) wrote a meta-analysis based on 10 different articles and looked at the different interventions in each one. Their study was over a 12-month period where they reviewed 1,288 articles, eliminating the ones that did not meet their standards. Strength and aerobic training (swimming, dancing, hiking, etc.) did not have a significant difference, so they decided to combine the data. They looked at different aspects that included the type of exercise, the weekly frequency, the duration of the intervention, and the intensity of the exercise (Coutinho, 2013). Some articles they found were ones that discussed the effects of exercise alone, while others evaluated the use of exercise combined with medications. Both aerobic training and strength training played a role in reducing the depressive symptoms. In the article, they concluded that exercise could be used in the place of antidepressants to reduce hospital visits and the use of medications. They concluded that physical exercise, mainly aerobic training, helped improve depressive symptoms, and therefore, helped treat it (Coutinho, 2013). They also discovered that age and symptom severity played a role in the results.

In a different meta-analysis, Richards (2106) was interested in looking at the mean change in depressive symptoms. He focused his research on randomized control trials. Initially, there were 819 potentially relevant articles, with only 25 articles meeting the criteria in the end. The participants in the study were limited to only those with major depressive disorder. He came to the conclusion that there is evidence that exercise can be considered an evidence-based treatment for the management of depression.

Qualitative Research and Social Media

Qualitative research is exploratory in nature and provides insights into a problem. The first qualitative article I found was one in which Danielsson and colleagues (2016) interviewed 13 people who participated in aerobic exercise which was guided by physical therapy. This article specifically focused on the patients’ perspectives because the authors believe that is an important aspect. The participants had to have a diagnosis of Major Depressive Disorder and be willing to participate in the exercise regimen. In the interviews, they asked open-ended questions focusing on direct and indirect changes, previous experiences of exercise, views on exercise during depression, and barriers and facilitators. The interviews all lasted between 29 and 65 minutes. After comparing all of the results and doing some research, Danielsson and colleagues (2016) came to the conclusion, “Exercise in a physical therapy context can improve the patients’ perceptions of their physical ability and create a sense of liveliness, improving their depressed state.”

The second study from Busch (2016), consisted of a survey that was given to 102 individuals, in which 50% of them were female. There were barriers within the study which included fatigue, mood, and lack of motivation. However, both genders were interested in an exercise program for depression. Overall, the participants prefer an exercise regimen that is coached, 30-60 minutes in length, occur multiple times per week, is provided in the patient’s home and is offered on the individual level (Busch, 2016).

Quantitative Research

Quantitative research is done by collecting data from different sources and analyzing it in a structured way. This may include clinical trials, randomized control trials, experiments, or surveys. In a quantitative study by Helgadottir and colleagues (2016), a single-blind, randomized control trial which lasted 12 weeks was conducted. Measurements were observed at baseline and post-treatment. There were 4 different treatment groups: vigorous exercise, moderate exercise, light exercise, and treatment as usual. There were 620 American participants in the study, ranging from age 18-67 years old, with the majority being women. Participants had to have a score greater than 10 on the Depression Patient Health Questionnaire (PHQ-9) to be considered for the trial. The light exercise consisted of yoga, moderate exercise consisted of aerobic conditioning, and vigorous exercise consisted of aerobic conditioning. Treatment as usual consisted of either cognitive-behavioral therapy or counseling sessions. In the end, the authors concluded that there were no differences between the groups; any level of exercise is effective in treating mild to moderate depression (Helgadottir, 2016). All of the exercise intensity levels had lower depression severity levels than the treatment as usual group.

In a similar study conducted by Cangin and colleagues (2018), data from four surveys was collected, in which there were 3,935 women and 3,419 men who participated in the study. Fewer women exercised on a daily basis than men, whereas fewer men were clinically depressed. This study was interesting because it was one of the few to have at least 1,000 participants. In conclusion of this study, a regimen that consisted of exercise for at least 150 minutes a week of moderate-intensity proved to decrease depressive symptoms in the participants. An equivalent to this would be 75 minutes of vigorous activity a week.

Clinical Guidelines

Clinical guidelines are statements with intentions to optimize patient care by including knowledgeable recommendations. In one clinical guideline I reviewed, the American College of Physicians (2016) compared the use of second-generation antipsychotics (SGA) with exercise. Sertraline, a common SGA, has adverse effects that could lead to its discontinuation, while exercise does not have any adverse effects. This is a major aspect they looked at since adverse effects can be overwhelming and discouraging. Overall, the recommendation is to use exercise or cognitive-behavioral therapy to treat middle-aged women with major depressive disorder, over the use of second-generation antipsychotics alone (American College of Physicians, 2016). They claimed that patients should exercise at least two times a week with moderate intensity (running, bicycling, dancing, etc.). The use of physical activity in the treatment of depression was associated with positive outcomes.

In another clinical guideline by Thompson (2018), there are new guidelines set in place for patients with depression in the hospital. These guidelines discuss how any amount of exercise at all can improve depressive symptoms, and it can all be done in 1-2 days. It does not have to be drawn out throughout the week. Something as simple as climbing a flight of stairs can even provide health benefits. This was interesting because this was the only article found that concluded this.

Recommendations

Clinical Recommendations

One clinical recommendation I would make is to have the nurse talk to an exercise specialist who can help create an exercise regimen specific to each patient with major depressive disorder. The nurse can write down the weekly plan and give it to the patient, so he or she is able to take it home. The nurse could also provide music recommendations for the patient, as research above has indicated that this keeps the patient engaged. Collaborating with an exercise specialist will ensure the best exercise regimen is created for each patient (Coutinho, 2016). Information on gyms near the patient’s home may also be helpful so they know their options of where to go.

Another clinical recommendation I would make is to encourage any patient with major depressive disorder to exercise at least fifteen minutes on a daily basis and keep a log of it. This could help improve their moods and release those endorphins that I mentioned above. Keeping a log would help keep the patient on track and see what improvements could be made. It will also help to get in a routine. Also, setting them up with an exercise partner may help motivate them more than a doctor would. They can then push each other and hold each other accountable for sticking to their goals.

Research Methodology Recommendations

One research methodology recommendation I would make is to look at how much exercise is needed to reach and maintain a therapeutic level. Also, researchers should look at how often the exercise is needed. There was only one article that addressed these aspects and the conclusions were vague. A lot of the articles concluded that exercise does improve depressive symptoms, but there was lack of evidence to determine how much and how often it is needed. Participants could be divided into different groups based on the level of intensity of the physical activity and how often they exercise.

Another research methodology recommendation I would make is to observe participants over a longer period of time. Most of the articles examined participants over a 6-week period, which does not address the long-term effects of exercise. There should be trials that last at least six months, so the improvements or setbacks can be compared to the baselines.

Conclusion

The effect of exercise on depression has a clear impact on the nursing community. Nurses are in contact with depressed patients on a daily basis, whether that is their presenting complaint or not. If nurses can provide patients with ways to reduce their depressive symptoms, that can help both the nurse and the patient. It also has an impact on nursing because it is a nurse’s responsibility to make sure patients are safe and not a danger to oneself or the community. If an exercise can decrease the chances of depression-induced suicide, a nurse is potentially saving that person’s life.

Abstract

With the rising number of clinically diagnosed teens and adults, there is also a need for different treatments due to the different lifestyles of individuals. Newer advances such as a new use for ketamine, acupuncture therapy, and even a mild form of therapeutic shock therapy have all shown to improve one’s condition by either working side by side the antidepressant medication, or completely replacing it altogether. All three methods have shown to improve one’s rating on the depression scale by lowering their score dramatically.

New Research is Finding More Ways to Cope with Major Depressive Disorder

Major depressive disorder is one of the most prevalent mental illnesses within the population. According to the National Institute of Mental Health, a reported 6.7% of the adult population being clinically diagnosed with the illness, meaning that approximately 14.8 million Americans are diagnosed. In adults, this disorder leads to a lower quality of life and makes it harder to accomplish everyday tasks as well as maintain healthy social interactions. Symptoms of this disease include diminished levels of self-esteem, and lack of energy or daily motivation. Episodes of this disorder can linger from days to weeks if not being constantly treated

Treatments.

Treatments for this illness are necessary for individuals proceed in living productive, normal lives. Luckily there is a long list of proven treatments to help people find the best fit for themselves. From medication to acupuncture therapy, to even sometimes shock therapy

Acupuncture Therapy.

Acupuncture is mostly known to the public as a seemingly painless way to help release negative energy that is stored deep inside our bodies. Recently, researchers have been testing the effectiveness of this procedure on those diagnosed with major depressive disorder or MDD. Multiple studies were conducted by RAND Corporation, trying to determine the effects of acupuncture on participants diagnosed with major depressive disorder. The participants were adults between the ages of 30 and 49. Of the three studies, the researchers were trying to determine the best way to incorporate acupuncture into one’s treatment of MDD. Participants were tested with and without their usual antidepressant medication to possibly try to replace that medication in some participants. At the end of the study, most participants receiving conventional acupuncture reported that the acupuncture on its own did not show much improvement in their depression scores. On the other hand, participants taking antidepressants while also receiving conventional acupuncture scored much lower on a depression scale.

Repetitive Transcranial Magnetic Stimulation (rTMS).

Repetitive transcranial magnetic stimulation (rTMS) has become a more widely accepted form of major depressive disorder treatment over recent years. In 2008, the treatment was approved for treatment of individuals who were or became resistant to normal anti-depressants. Although clinical guidelines limited the testing of subjects because of the increased risk of lowering a subject’s seizure threshold. With the addition of medications such as antiepileptics, benzodiazepines, or other medications with anticonvulsant properties, researchers were able to continue their study alongside adding the subject’s original anti-depressant medication in order to conclude whether or not repetitive transcranial magnetic stimulation would increase the drugs ability to function as it normally should within the patient. The testing took place at UCLA, within their own research facility and research program. All 227 patients were tested from 2009-2017. Of that, 181 participants continued use of at least one psychotropic medication (92%) or antidepressant (72%). Treatment took place using the NeuroStar TMS System (Neuronetics, Inc, Malvern, PA 30 separate times, scheduled over six weeks. The start of treatment starts slow, beginning by using parameters of 3,000 pulses per session at 10 Hz administered to the left dorsolateral prefrontal cortex with a 40‐pulse train and intertrain interval of 26 seconds, for a total duration 37.5 min. Intensity was amplified to 120% of the resting motor threshold as the subject tolerated. After the first two weeks, minor adjustments were made to treatment. Treatment adjustments were guided by changes in symptom severity, and physician clinical judgment, within established treatment guidelines. After the trial was concluded, Subjects showed an average improvement of wellbeing on the depression score scale (7.9 ± 9.8 points on the IDS‐SR after 2 weeks of treatment). Change in symptom severity at week 2 was not associated with gender, although the older the subject, the greater showed improvement. After 6 weeks of treatment, subjects improved even more (13.8 ± 12.1 points). During week 6, not only was the patient’s depression score improving, but also their anxiety subscale (r = −0.16, p = 0.05). This study concluded by stating that the use of benzodiazepine was less helpful to the subjects, whereas psychostimulant use much more rewarding over the time studied. Over recent years, the correlation between medication use and more invasive clinical trials were beginning to become more widely accepted in the medical and psychological fields. Given that psychostimulant effects were observed at week 2 and across six weeks of treatment, this medication category may be more likely to be associated with rTMS outcome for depression regardless of treatment duration, or the site/frequency of stimulation.

Ketamine.

Ketamine originally started out in the United States as an anesthetic in the 1970s and was soon replaced with a newer more advanced drug. Once ketamine lost its medical use, it was beginning to be used for non-medical purposes and was becoming more of a party drug used for recreation. Only recently have psychologists started to weigh the odds and look at some of its adverse effects on the human brain. New research has proven that the glutaminergic pathway is an alternative target mechanism in the treatment of major depressive disorders. The glutaminergic houses more receptive and powerful neurons. In fact, ketamine targets this portion of the brain, making it very effective. Within the Cochrane systemic review, participants showed significant results in 3 randomized controlled trials with 56 adult participants. This showcased that the response rate of ketamine compared with placebo was excelling at 24 and 72 hours. The odds ratio at 24 hours was 10.77 (95% confident interval [CI] = 2.00–58.00); and at 72 hours was 12.59 (95% CI = 2.38–66.73). Meanwhile, data from 4 randomized controlled trials with 131 participants revealed an odds ratio of 2.58 (95% CI = 1.08–6.16) at a 1-week interval. Interestingly, at a 2-week interval, only 1 study reported no difference in response rate between ketamine treated group and placebo. Repeated dosing of IV ketamine at 0.5 mg/kg given 3 times per week for a total of 6 doses over a 12-day period resulted in a significant reduction of depression symptoms as measured by the Depression Rating Scale. This therapeutic effect was observed beginning at 2 hours after the first dose of ketamine infusion and persisted throughout the treatment duration. Unfortunately, relapses were noticed among the responders on an average of 18 days after the last dose of ketamine. This suggests that ketamine has a rapid onset with limited duration effect on depression.

References

1. Sorbero, M., Reynolds, K., Colaiaco, B., Lovejoy, S., Farris, C., Vaughan, C., . . . Herman, P. (2015). Discussion. In Acupuncture for Major Depressive Disorder: A Systematic Review (pp. 33-48). RAND Corporation. Retrieved from www.jstor.org/stable/10.7249/j.ctt19rmd2p.13
2. Depression. (n.d.). Retrieved from
3. https://www.nimh.nih.gov/health/topics/depression/index.shtml.
4. Hunter, A. M., Minzenberg, M. J., Cook, I. A., Krantz, D. E., Levitt, J. G., Rotstein, N. M., …
5. Leuchter, A. F. (2019). Concomitant medication use and clinical outcome of repetitive Transcranial Magnetic Stimulation (rTMS) treatment of Major Depressive Disorder. Brain and Behavior, (5). https://doi-org.zeus.tarleton.edu/10.1002/brb3.1275
6. Luu, B., Rice, E., & Goldin, P. (2019). Ketamine in the Treatment of Major Depressive Disorder. The Journal for Nurse Practitioners.
7. https://doi-org.zeus.tarleton.edu/10.1016/j.nurpra.2019.07.016

Background and review of literature

Major depression, characterized as a “common cold” of psychiatry severely limits psychosocial functioning and diminishes quality of life. It is predicted that the burden of Major depressive disorder (MDD) on the modern society will be the largest of all diseases by 2030 (World Health Organization, 2008). The recent National Mental Health Survey (2015-2016) revealed that the lifetime prevalence of depression in India was 5.25% among individuals aged 18 Years and above and the current prevalence was 2.68%.

DSM-5 defines a major depressive episode as a period of two weeks or more in which at least five symptoms are expressed most of the day nearly every day, including either depressed mood or the loss of interest in nearly all activities, weight/appetite disturbance, sleep disturbance, psychomotor agitation/retardation, fatigue, feelings of worthlessness/guilt, decreased concentration/decision-making, and suicidal ideation.

Major depressive episode last for an average of 6 months (Rhebergen et al., 2010) and has high rates of relapse and recurrence (Figueroa et al., 2015). With each depressive episode, an individual’s chance of enduring an additional episode increases by approximately 15% (Seemuller et al., 2010). MDD is a prevalent condition with 12-month estimates being 4.2% in men and 9.9% in women (Maske et al., 2016). Despite wealth of research concerning the assessment, diagnosis, and treatment of depression, limitations in the knowledge regarding relapse are still evident. However, rather than focusing on identifying the causes of first episodes of depression, several researchers have narrowed their search to identify the causes of recurrence in particular, which may be different from the causes of first episodes (Lewinsohn, Allen, Seeley, & Gotlib, 1999).

Cognitive Reactivity and Depression

Cognitive theories of depression show widespread consensus that cognition is an important factor in unipolar depression (Ingram, Miranda, & Segal, 1998). The most central concept is that dysfunctional cognitions are considered to be the key vulnerability factor, both for the first onset and for recurrences of depression (Beck, 1967; Teasdale, 1988; Clark et.al.,1999).

Cognitive reactivity (CR) refers to the ease with which dysfunctional attitudes are activated by sad mood states (Van der Does, 2002). It is defined as the relative ease with which maladaptive cognitions or cognitive styles are triggered by mild (non-pathological) mood fluctuations (Ingram, Miranda & Segal, 1998). From a cognitive science perspective, it has been suggested that sensitization (and increased risk of relapse and recurrence) is brought about by increased cognitive reactivity to small changes in depressed mood (Segal, Williams, Teasdale & Gemar, 1996). Cognitive reactivity is not only an important factor in the onset (Kruijt et al., 2013) and maintenance of depressive symptoms (Struijs et al., 2013) but especially important for depressive relapse/recurrence.

The mechanisms involved in a first onset of depression may differ from those involved in recurrences (Monroe and Harkness, 2011). High cognitive reactivity may also increase the risk of recurrence of depression and two studies using mood induction procedures have shown cognitive reactivity to be a significant predictor of recurrence over periods of 15 and 18 months after remission (Kuyken et al.,2010). Moulds et al., (2008) found that formerly depressed participants had significantly higher LEIDS-R scores than never depressed participants. Segal, Gemar, and Williams (1999) discovered that CR, as measured by the change in Dysfunctional Attitude Scale scores pre/post mood induction procedures, predicted depressive relapse after 31 months, at the same time that they reported that participants treated to remission with CBT showed less CR than those treated to remission with medication.

Metacognition and Depression

Flavell (1979) introduced the concept of meta-cognition and defined it as “cognitions about one’s cognition”. Wells & Cartwright-Hatton, 2004 define meta-cognition as “the psychological structures, knowledge, events, and processes that are involved in the control, modification, and interpretation of thinking itself”.

Meta-cognitions are shown to be unhealthy when operating in a pattern known as the Cognitive Attentional Syndrome (CAS) which consists of worry, rumination, fixed attention, and unhelpful self-regulation strategies or coping behaviors. CAS is conceptualized as ‘‘aspects of cognition that control the way a person thinks and behaves in response to a thought, belief or feeling’’ (Wells 2009).

Metacognitions about worry have also been proposed as a promising vulnerability marker of depressive relapse (Halvorsen et al., 2015). Individuals with a history of depression tend to worry about relapsing (Sarisoy et al., 2013) Sarisoy et al., (2013) found that ‘Negative beliefs about worry concerning uncontrollability and danger’ was elevated both in unipolar and bipolar depressed individuals compared to the non-depressed control group. Meta-cognitive beliefs are significantly effective on prediction of depression and anxiety. Moreover, out of meta-cognitive elements, only general negative beliefs, in comparison with other elements, may predict the depression (Delavar et al.,2014)

Beliefs About Rumination and Meta-cognition:

The Meta-cognitive Model suggests that depressed individuals use rumination to deal with stress and trigger thoughts. Rumination is a thinking style that typifies depression and has been linked to the maintenance of depressive episodes (Nolen-Hoeksema, 1991; Teasdale & Barnard, 1993) but may also represent a strategy intended to cope with depression. Rumination is defined as self-focused, persistent, recurrent, negative thinking (Papageorgiou & Wells, 2004).

Active and perseverative thinking, in the form of rumination or worry, is linked to positive and negative metacognitive beliefs about these processes (Cartwright-Hatton & Wells, 1997; Wells & Papageorgiou, 1998). Positive beliefs about rumination motivate individuals to engage in rumination as they may believe that analyzing why they are depressed will help them to snap out of their depression. However, rumination leads to distress which again activates negative beliefs about this mental process such as having no control of one’s thinking and fearing the mental, physical, and interpersonal consequences of rumination. Papageorgiou and Wells (1999) found that depressed patients believed that rumination was helpful for solving problems and understanding depression, but also that rumination was uncontrollable and dangerous. In a longitudinal study by Matsumoto & Mochizuki, 2018, negative meta-beliefs predicted high depressive symptoms, and depressive symptoms predicted high negative meta-beliefs. Negative meta-beliefs predicted high uncontrollability of rumination, whereas uncontrollability of rumination did not predict depressive symptoms.

Cognitive Coping:

Dysregulation of emotions typically characterizes mood and anxiety disorders (Gross and Thompson, 2007). Cognitive coping is defined as the conscious, mental strategies individuals use to handle the intake of emotionally arousing information (Garnefski et al., 2001). Two major strategies that have been particularly studied are cognitive reappraisal and expressive suppression (Gross and John, 1998). Cognitive reappraisal is defined as the attempt to reinterpret an emotion-eliciting situation in a way that alters its meaning and changes its emotional impact (Gross and John, 2003). Expressive suppression is defined as the attempt to hide, inhibit or reduce ongoing emotion-expressive behavior (Gross and John, 2003). People who experience depression rely more on expressive suppression than cognitive reappraisal to evade adverse emotional states. Therefore they may experience increased depression in the long term (Campbell & Barlow, 2007). Findings have indicated that expressive suppression is associated with increased depression symptoms (Joormann & Gotlib, 2010). Moreover, emotion suppression has been associated with increased use of rumination (Liverant, Kamholz, Sloan, & Brown, 2011). Indeed, recent studies demonstrate that voluntary changes of the interpretation of a situation can change the intensity of an emotional reaction (Gross, 1998; Ochsner, Bunge, Gross, & Gabrieli, 2002; Ochsner et al., 2004). Habitual use of reappraisal vs. expressive suppression has been shown to be associated with the experience and expression of greater positive affect and lesser negative affect, better interpersonal functioning, and increased well-being (Gross & John, 2003).

In summary, Cognitive Reactivity is an important cognitive feature in depression as it predicts the onset, relapse or recurrence of a depressive episode. However, it has mostly been studied in patients with previous depressive episodes and healthy groups. Therefore, the relationship between cognitive reactivity and currently symptomatic groups is being entailed in this study. Existing literature also reveals that there exists a relationship between meta-cognition and depression. Nevertheless, existing studies have focused either on healthy samples or already depressed individuals (Sarisoy et al. 2013) or have compared depressed patients with those having anxiety disorders. None of the studies investigated the presence of meta-cognitions in individuals in different phases of Major Depressive Disorder.

Bibliography

1. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (text revision – fourth). Washington, D.C.: American Psychiatric Association.
2. American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (DSM 5) (5th ed.). Washington, DC: American Psychiatric Association.
3. Campbell-Sills, L., and Barlow, D.H. “Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders”. In J.J. Gross (Ed.), Handbook of emotion regulation (pp. 542-559), 2007. New York: Guilford Press.
4. Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and intrusions: The Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11, 279-296.
5. Clark, D.A., Beck, A.T., Alford, B.A.,1999.Scientific Foundations of Cognitive Theory and Therapy of Depression. John Wiley & Sons Inc., Hoboken, NJ, US.
6. Figueroa, C. A., Ruhé, H. G., Koeter, M. W., Spinhoven, P., van der Does, W., Bockting, C.L., & Schene, A. H. (2015). Cognitive reactivity versus dysfunctional cognitions and the prediction of relapse in recurrent major depressive disorder. The Journal of Clinical Psychiatry, 76, 1306-1312. DOI: 10.4088/JCP.14m09268
7. Flavell, J. H. (1979). Metacognition and cognitive monitoring: A new area of cognitive-developmental inquiry. American Psychologist, 34(10), 906–911.
8. Garnefski, N., Kraaij, V., & Spinhoven, P. (2001). Negative life events, cognitive emotion regulation, and depression. Personality and Individual Differences, 30, 1311–1327.
9. Gross, J. J., and John, O. P. (1998). Mapping the domain of emotional expressivity: multi-method evidence for a hierarchical model. J. Pers. Soc. Psychol. 74, 170– 191. DOI: 10.1037//0022-3514.74.1.170
10. Gross, J. J., and John, O. P. (2003). Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J. Pers. Soc. Psychol. 85, 348–362. DOI: 10.1037/0022-3514.85.2.348
11. Gross, J. J., and Thompson, R. A. (2007). “Emotion regulation: conceptual foundations,” in Handbook of Emotion Regulation, ed J. J. Gross (New York: Guilford Press), 3–24.
12. Halvorsen M., Hagen R., Hjemdal O., Eriksen M. S., Sørli Å. J., Waterloo K., et al. (2015). Metacognitions and thought control strategies in unipolar major depression: a comparison of currently depressed, previously depressed, and never depressed individuals. Cogn. Ther. Res. 39, 31–40. 10.1007/s10608-014-9638-4
13. Ingram, R. E., Miranda, J., & Segal, Z. V. (1998) Cognitive vulnerability to depression. New York: Guilford Press.
14. Joormann, J. (2010). Cognitive inhibition and emotion regulation in depression. Current Directions in Psychological Science, 19, 161–166. doi:10.1177/0963721410370293
15. Kuyken,W., Watkins,E., Holden,E., White,K., Taylor,R.S., Byford,S., Dalgleish,T., et al.,2010.How does mindfulness-based cognitive therapy work? Behaviour Research Therapy.48(11),11051112. http://dx.doi.org/10.1016/j.brat.2010.08.003.
16. Kruijt, A. W., Antypa, N., Booij, L., de Jong, P. J., Glashouwer, K., Penninx, B. W. J. H., et al. (2013). Cognitive reactivity, implicit associations, and the incidence of depression: A two-year prospective study. PLoS ONE, 8, e70245. DOI: 10.1371/journal.pone.0070245.
17. Lewinsohn PM, Allen NB, Seeley JR, Gotlib IH. First onset versus recurrence of depression: Differential processes of psychosocial risk. Journal of Abnormal Psychology. 1999;108(3):483–489.
18. Liverant, G. I., Kamholz, B. W., Sloan, D. M., & Brown, T. A. (2011). Rumination in clinical depression: A type of emotional suppression? Cognitive Therapy and Research, 35, 253–265. doi:10.1007/s10608-010-9304-4
19. Maske, U. E., Buttery, A. K., Beesdo-Baum, K., Riedel-Heller, S., Hapke, U., & Busch, M. A. (2016). Prevalence and correlates of DSM-IV-TR major depressive disorder, self-reported diagnosed depression, and current depressive symptoms among adults in Germany. Journal of affective disorders, 190, 167-177.
20. Matsumoto, N., & Mochizuki,S., (2018). Why do People Overthink? A Longitudinal Investigation of a Meta-Cognitive Model and Uncontrollability of Rumination. Behavioral and Cognitive Psychotherapy: page 1 of 6. doi:10.1017/S1352465818000103
21. Monroe, S.M., Harkness, K.L.,2011.Recurrence in major depression: a conceptual analysis. Psychol.Rev.118(4),655–674. http://dx.doi.org/10.1037/a0025190.
22. Moulds, M. L., Kandris, E., Williams, A. D., Lang, T., Yap, C., & Hoffmeister, K. (2008). An Investigation of the Relationship Between Cognitive Reactivity and Rumination. Behavior Therapy, 39(1), 65.
23. National Mental Health Survey of India, 2015–16. Prevalence, Pattern, and Outcomes. Bengaluru: National Institute of Mental Health and Neuro Sciences; 2016
24. Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100, 569-582.
25. Papageorgiou, C., & Wells, A. (1999). Process and metacognitive dimensions of depressive and anxious thoughts and relationships with emotional intensity. Clinical Psychology and Psychotherapy, 6, 156-162.
26. Papageorgiou, C., & Wells, A. (2001). Positive beliefs about depressive rumination: Development and preliminary validation of a self-report scale. Behavior Therapy, 32, 13–26.
27. Pageorgiou, C.,& Wells, A. (2009). An Empirical Test of clinical meta-cognition model of Rumination and Depression. Cogn Ther and Res; 27(3): 261-273.
28. Rhebergen, D., Beekman, A. T., deGraaf, R., Nolen, W. A., Spijker, J., Hoogendijk, W.J., & Penninx, W. (2010). Trajectories of recovery of social and physical functioning in major depression, dysthymic disorder and double depression: A 3-year follow-up. Journal of Affective Disorders, 124, 148-156.
29. Sarisoy, G., Pazvantoglu, O., Ozturan, D. D., Ay, N. D., Yilman, T., Mor, S., et al. (2013). Metacognitive beliefs in unipolar and bipolar depression: A comparative study. Nordic Journal of Psychiatry.Published online August 1, 2013. doi:10.3109/08039488.2013.814710.
30. Seemuller, F., Riedel, M., Obermeier, M., Bauer, M., Adli, M., Kronmuller, K.,Mooler, H.J. (2010). Outcomes of 1014 naturalistically treated in-patients with major depressive episodes. European Neuropsychopharmacology, 20(5), 346-355.
31. Segal, Z. V., Williams, J. M. G., Teasdale, J. D., & Gemar, M. (1996). A cognitive science perspective on kindling and episode sensitization in recurrent affective disorder. Psychological Medicine, 26, 371– 380.
32. Segal, Z. V., Gemar, M., & Williams, S. (1999). Differential cognitive response to a mood challenge following successful cognitive therapy or pharmacotherapy for unipolar depression. Journal of Abnormal Psychology, 108(1), 3-10.
33. Struijs, S. Y., Groenewold, N. A., Voshaar, R. C. O., & de Jonge, P. (2013). Cognitive vulnerability differentially predicts symptom dimensions of depression. Journal of Affective Disorders, 92–99.
34. Teasdale, J.D.,1988.Cognitive vulnerability to persistent depression.Cogn.Emot.2 (3), 247–274.
35. Teasdale, J. D., & Barnard, R J. (1993). Affect, cognition and change: Re-modelling depressive thought. Hove, UK: Lawrence Erlbaum Associates.
36. Van der Does, A. J. W. (2002). Cognitive reactivity to a sad mood: Structure and validity of a new measure. Behaviour Research and Therapy, 40, 105– 120.
37. Wells, A. and Cartwright-Hatton, S. (2004) A Short form of the Metacognition Questionnaire: Properties of the MCQ- 30. Behaviour Research and Therapy, 42, 385-396. http://dx.doi.org/10.1016/S0005-7967(03)00147-5
38. Wells, A. (2009). Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Wiley.
39. World Health Organization, 2008. The Global Burden of Disease: 2004 Update.

Aims and objective

• To study Cognitive Reactivity and Meta-cognition in patients with First Episode Major Depressive Disorder, Recurrent Major Depressive Disord,er and healthy control and to make comparisons among them.
• To explore the relationship between Cognitive Reactivity and Meta-cognition in patients with First Episode Major Depressive Disorder and Recurrent Major Depressive Disorder, if any.

Study design

It will be a cross-sectional and non-interventional study in a clinical population in a tertiary care hospital setting.

Method

In this study, all newly registered and old patients who are currently symptomatic, attending Adult Psychiatry OPD, KGMU, and have been diagnosed with First Episode Major Depressive Disorder or Recurrent Major Depressive Disorder by the consultant in-charge will be screened for inclusion in the study. Patients willing to give informed consent will be screened using Mini International Neuropsychiatric Interview (M.I.N.I. 7.0.2) to rule out co-morbid psychiatric disorders.

If the patient is eligible for the study, their socio-demographic data, family, and clinical history will be recorded on the semi-structured proforma. Beck Depression Inventory-II (BDI-II) will be administered to assess the current level of severity of depression in the symptomatic patients.

Healthy volunteers will be taken up in the control group from the community (The researcher’s neighborhood and informants accompanying the patient attending the Adult Psychiatry OPD in KGMU, Lucknow). Those who shall provide written informed consent and fulfilling the criteria will form the study sample. Global Health Questionnaire-12 (GHQ-12) will be administered on participants in the healthy group and they shall be matched on age, sex, and education. Questionnaires of Cognitive Reactivity (Leiden Index of Depression Sensitivity- Revised), Meta-cognition (Meta-cognition Questionnaire-30), Cognitive Coping (Emotion Regulation Questionnaire), and Beliefs about Rumination (Positive Beliefs about Rumination Scale and Negative Beliefs about Rumination Scale) shall be administered on both the symptomatic groups (First Episode Major Depressive Disorder and Recurrent Major Depressive Disorder) and the healthy group. Administration of questionnaires will be clinician-assisted as and when required. The obtained data will be statistically analyzed and interpreted with the help of the computer-based statistical tool SPSS (24 versions).

Intervention

Setting

Psychiatry Department – Clinical Psychology Unit (Department of Psychiatry, K.G.M.U, Lucknow, U.P.)

Inclusion and exclusion criteria for the study group (First Episode Major Depressive Disorder And Recurrent Major Depressive Disorder**)

Inclusion Criteria:

• Patients with a diagnosis of First Episode Major Depressive Disorder or Recurrent Major Depressive Disorder according to DSM 5.
• Patients willing to give written informed consent.
• Adults (≥18 to 60 years age)
• Patients having score ≥14 on BDI-II.
• Not receiving any psychological treatment for their current depressive episode**

Exclusion Criteria:

• Patients with any other co-morbid psychiatric disorder.
• Patients with suicidal intent and those diagnosed with severe depression with psychotic symptoms.
• Patients with a physical disability or condition requiring priority medical management.
• Patients who are unable to comprehend the questionnaires or are unable to co-operate for the interview.

Inclusion and exclusion criteria for healthy control group

Inclusion Criteria:

• Adults(≥18 to 60 years age)
• Participants willing to volunteer and give written informed consent.

Exclusion Criteria:

• Presence of any psychiatric disorder (GHQ-12 score ≥3)
• Participants who are unable to comprehend the questionnaires or are unable to co-operate for the interview.

The sample size for primary outcomes

The sample size was estimated to be 40 in each of the two clinical groups (Patients with First Episode Major Depressive Disorder and Recurrent Major Depressive Disorder) and 40 healthy control group participants (determined using weighted prevalence rate for current experience of 2.68% from National Mental Health Survey 2015-2016) using the following formulae:

n = Zα/22 ­*p*(1-p) / MOE2

• where, Zα/22 is the critical value of the Normal distribution at α/2 (for a confidence level of 95%, α is 0.05 and the critical value is 1.96),
• p is the sample proportion [prevalence value is 0.0268 (2.68%)]
• MOE is the margin of error (value is 0.05),

However, because of brevity of time the investigator will strive to obtain a minimum sample of 30 patients in each of the two clinical groups (Patients with First Episode Major Depressive Disorder and Recurrent Major Depressive Disorder) and 30 healthy control group participants. Patients and participants over and above minimum shall be in included in the two clinical groups and healthy control group if time permits the investigator.

Introduction to Fictional Characters and Psychological Disorders

Undergoing a psychological disorder can alter people all around the world on an everyday basis, although has anyone ever wondered if a fictional character from a motion picture, TV show, novel, etc., is engaged with a psychological disorder well. This paper is going to address a fictional character and how she has been diagnosed with major depression. Now major depression for anyone who is not acquainted with this disorder is a psychological obstacle that usually makes people experience profoundly saddening emotions, not want to do anything that they use to appreciate, and thinking low about themselves. The fictional character who is going to be the primary star of this paper is the youthful, pure, high school girl we all love from the Twilight franchise, Bella Swan. It is no shock that Bella would be prone to bearing major depression since she is constantly running around with vampires and werewolves. This paper is going to discuss the background/history of Bella, prevailing symptoms she is experiencing, reasons why she has been authorized with this diagnosis, distinct diagnostic principles exploited, diagnoses that have been ruled out, and therapy or medication that is prescribed that will provide Bella with the support she needs to conquer or reduce the power of her psychological disorder.

Bella Swan’s Background and Emotional Turmoil

Bella, by good luck, felt serene enough to discuss and relive the history of her life based solely on the fact that she is not acting like the same person that she is usually, and she wants to find out why. At the age of 17, Bella moved from Arizona to Washington to live with her father due to her parents acquiring a divorce, and she has wanted a new change of scenery. Life events that can negatively impact people can be the reason for depression to emerge in someone’s life, notably young children experiencing the divorce of their parents. She made new friends right away on her first day of attending her new high school, and she also bumped into someone who would soon become her boyfriend, although right now Bella is disconnecting herself from the rest of her friends by eating by herself in the cafeteria, which is something she used to appreciate doing on an ordinary schedule with her friends, which can also be accounted as an emblem of depression. On her first day of school in Biology class, she met a 17-year-old young man named Edward Cullen, whom she started to date a couple of weeks later after their first meeting with each other.

Bella insists that Edward is a vampire who merely feeds on animals, but she did not go into any more detail regarding her comment on Edward. A year later, Bella claims that Edward and the rest of his family have left Washington for business and that Edward told her she does not want her to be associated with him anymore, which she holds is impacting her emotionally and behaviorally. Bella has begun to stop hanging out with her friends, she is having hardship sleeping (night terrors), she advances to sit in front of her bedroom window for numerous months on end, and fortunately, Bella’s father, Charlie Swan, has caught onto the matter that Bella is not herself and that she needs support to crush whatever is affecting her. Charlie would wake up to Bella screaming in her sleep, and he would have to constantly comfort her for many nights. Bella soon learns that enlisting in risky proceedings helps her feel better, but that is not really helping. As of now, that is Bella’s whole history of the significant stuff that has occurred in her life. Although a lot of symptoms Bella has encountered in the past 2 years have been addressed, it is still important to go into more depth on her symptoms and how they are associated with depression.

Symptoms and Association with Major Depression

Bella has and still is experiencing different manifestations that are associated with major depression. Her ongoing symptoms that she currently undergoes consist of remaining invariably pessimistic, she has a sense of discouragement, has an insufficient interest in things she used to love to perform, has inconvenience sleeping, has attempted suicide, her family has an excessively lengthy history of depression, her hunger has shifted, and she has endured a large-scale life changeable event. She had continually communicated with licensed psychologists about why she is sad, which is because Edward took off when she was in a weak state, and she had no idea whom to turn to for empathy. She has additionally stated that she stares out her window on end for months at a time, reflecting on Edward. She feels hopeless that she will never be with Edward again and that no one will want to love her as Edward did with her. She has little interest in things she used to like to do such, as hanging out with her friends at lunch and going shopping with her girlfriends.

At this moment, all she does most of the time is, reside in her room all day and stare out the window. Every night her father has stated that he wakes up to Bella screaming in her sleep due to night terrors regarding Edward. Formerly, she even went to the extreme and decided to bound off a cliff into a body of water, but luckily, she was not severely harmed. Her father has delved into their family history and has uncovered that Bella’s mother, grandmother, and all great-grandmother have endured depression throughout their life. When she and her father go out to eat at their favored bistro, she does not eat as much as she used to which, her father has commented on.

Lastly, the most likely reason she is behaving this way is that she has sustained a crucial mind-blowing event, which is when Edward left her. For Bella to be psychologically diagnosed with major depression, she must acquire at least five indications of major depression, and as this paragraph, advocates she currently has six symptoms of major depression. Ultimately, for someone to be diagnosed with major depression, they also must be enduring from distinct manifestations for at least two weeks, and Charlie has assured professional psychologists that she has been operating this way for a little over one year. Although Bella’s symptoms are linked with major depression the diagnostic criteria have not yet been discussed in this paper.

Treatment Options and Recommendations

Psychologists have authorized Bella Swan with acquiring major depression because she seems to be depicting assorted indications that are applied to major depressive disorder, including: experiencing one or mind-blowing crises, sidelining herself from activities she used to treasure to be a part of, she continues to have a complication while she sleeps at night, she has sorrowfully sought suicide once, her family has a long line of depression, and she has not been eating as normally as she has been in the days gone by. Bella’s past is equivalent to her diagnosis because she has experienced two life-changing events that include the separation of her parents and Edward leaving her out of the blue. She has stopped hanging out with her friends at all costs and has alternately chosen to hide in her room multiple hours of the day so she will not have to confront the outside world. Charlie confirms that Bella continues to have nightmares and that she wakes up in a pool of perspiration every night. When Bella was alone one day, she decided to jump off a cliff into the water, but she was fine, and the physicians who were with her in the hospital said that she had some badly bruised ribs.

Charlie has organized some exploration on their family history and has realized that three people, now including four, might have gone through depression, and Charlie has acknowledged that Bella is not eating as much as she used to. Many trials have been conducted on Bella to ensure that she unquestionably is being affected by this disorder. Psychologists have consulted Bella about her physical status/if she is taking good care of her body, asked Bella multiple inquiries about different symptoms she has had and alterations in demeanor and, professionals have concluded that Bella has melancholic featured symptoms of major depressive disorder. As the information intel, there is no better reason why Bella Swan should not be diagnosed with major depressive disorder, although to make sure other disorders have also been investigated.

Now to be confident that Bella is not being affected by another disorder that is comparable to major depression, qualified psychologists have considered other disorders and different symptoms related with symptoms related to depression. Psychologists have studied the symptoms of persistent depressive disorder, postpartum depression, psychotic depression, seasonal affective disorder, and bipolar disorder. Psychologists have overruled persistent depressive disorder because Bella does not show to be experiencing tiredness in fact, she has inconvenience sleeping, no trouble focusing on school, and no unreasonable rage. Persistent depressive disorder is even a temperate, segment of depression but, the fact that Bella has attempted suicide goes to show that Bella unquestionably does not have persistent depressive disorder because if she did, she would not have associated herself with something as dangerous as self-harm. Postpartum depression has been ruled out because Charlie and Bella’s mother, Renee, have guaranteed specialists that Bella has never had a baby, exclusively because she is only 17 so, that rules out postpartum depression instantly. Psychotic depression is not a choice because for someone to be recognized with psychotic depression, that person must suffer from seeing foreign stimuli that are not there and from deceptions, fortunately, though Bella has assured psychologists that she has not had illusions or fantasies of any kind in the past year. Seasonal affective disorder is not a potential disorder that Bella could have because for someone to be diagnosed with seasonal affective disorder, they must have the following symptoms: sleeping too much, bingeing, turbulence, or weight gain. Most importantly, Bella’s demeanor has not been in sync with seasons, which is what seasonal affective disorder is. Last but not least, licensed psychologists can rule out the judgment that Bella does not have bipolar disorder because she is not chipper one second and the next melancholy, she is constantly sad so, there is no way she could have bipolar disorder. Now that potential disorders have been ruled out and that Bella has officially been diagnosed with major depression now, she must be either prescribed medication or types of therapy.

Conclusion: The Impact of Major Depression on Fictional Characters

Many potential different sorts of regimen can be wielded to help Bella wrestle with her depression, such as taking antidepressants, associating oneself in psychotherapy, although not all drugs or therapeutics will effectively rehabilitate Bella’s depression. Nonetheless, it might reduce serious symptoms that she frequently faces. The type of medication that would be initially advocated for Bella to take would be what professionals call selective serotonin reuptake inhibitors because it does not provoke as many reactions as other anti-depressants, although if this type of medication does not revamp Bella’s mental well-being in any way, she might need to be advanced to tricyclic anti-depressants, which will most likely generate more harsh repercussions. If certain anti-depressants do not perform themselves, Bella might need to incorporate other drugs. Something that also needs to be taken to thought is that prior treatment taken in the Swan family’s history might reinforce Bella and her depression and that Bella might be hypersensitive to certain types of medications. Now that medications have been prescribed for Bella, it only makes sense that types of psychotherapy should be favored for her as well.

When assorted types of psychotherapy were being looked into for Bella, what was kept in mind was that since Bella is a teenager, she might have an upsurge in dangerous images/natures beyond the first few weeks she is involved in psychotherapy. Psychotherapy is adopted to transform unfavorable thinking’s into productive logic, being competent to condone unhappiness cautiously, connecting with other people again, etc. Since Bella has tried committing suicide, it is urged that she stay in a hospital overnight for a couple of days to keep an eye on her. Another choice would be upholding Bella to partake in either electroconvulsive therapy or transcranial magnetic stimulation. Electroconvulsive therapy is recommended for Bella in case she does not react to the recommended medication, and because she has been unsafe around suicide. In conclusion, transcranial magnetic stimulation is recommended for Bella because it should coincide with her nervous classification and standardize her depressive nature.

Primarily after the affairs of major depressive disorder and why the main character from the movie ‘Twilight’ has been diagnosed with depression have been examined in an all well-known, appealing approach, this understanding should illustrate a comprehensive well insight of what it means to have major depression and how much it can flip someone’s world upside down.