External Factors Contributing to Depression Depression is most commonly characterized by depressive moods and feelings of low self worth or guilt, a disease affecting approximately 121 million people (World Health Organization, 2011). Despite these high numbers, the many factors that contribute to depression remain under debate. Depression is commonly treated with antidepressant medication that aims to normalize brain function, often through the uptake of neurotransmitters such as serotonin (Moncrieff, 2010). Research has supported the use of this type of medication with results that indicate prolonged use of antidepressants can reduce the chances of relapse (Kim, Lee, Paik, & Kim, 2011). Many deduce that because medication targets and treats physical abnormalities related to depression, biology must be the main contributor. Against this rational however, much research that exists today declares a balance of biology and external factors as contributors to depression (Cole, McGuffin, & Farmer, 2008). In contrast to discoveries of this nature, a study conducted in Taiwan concludes that many depression sufferers perceive the cause of their depression to be social and cultural factors, making little mention to biology (Fu & Paraboo, 2009). Although medication has proven successful in many cases for alleviating depressive symptoms, considerable amounts of research have determined that external factors such as personal misfortunes or stress, cultural and societal influences, such as social norms, and socioeconomics can impact the onset of depression (Kendler, Karkowski, & Prescott, 1999). This ongoing and complex argument of the extent to which external factors contribute to depression will be discussed in this essay, with the aim of proving that biology is not the core contributor to depression. Depression is a very common disease, affecting approximately 10%-25% of women and 5%-12% of men worldwide (American Psychiatric Association, 1994, pp. 317-391). Symptoms of depression commonly include feelings of pessimism, anxiousness and fatigue, as well as loss of appetite or overeating (National Institute of Mental Health, 2011). Diagnosing depression is not an easy task, due to varying symptoms in each patient. A study by Thomas-Maclean, Stoppard, Miedema and Tatemichi (2005) found that three common methods of diagnosis were used by primary care physicians, including the use of checklists, interpersonal process and intuition. The findings indicate that the most effective means of diagnosis includes negotiation with a patient, including a good doctor-patient relationship, with the doctor having substantial experience in depression and diagnosis. The age at which depression is diagnosed differs with each individual, with a particularly common age being during adolescence. A recent study by researchers Frye and Liam (2011) suggests that adolescence is the time where depressive symptoms are most likely to develop, but by the point of emerging adulthood, these symptoms settle dramatically, especially in women. Yet despite this stability, other research shows an increase of depressive symptoms later in life, with earlier onset for women than men (Lavretsky, Lesser, Wohl, & Miller, 1998). Despite the large quantities of research and knowledge on the subject, many with depression do not actively seek treatment. For those that do, many turn to medication; however a large increase in the use of alternative treatments, such as herbal medicinal products has developed (Reed & Trigwell, 2006). Depression is a stressful and difficult disease to deal with and in very harsh circumstances, can lead to suicide, which is clearly considered a serious clinical problem (Viava et al., 2011), which is why investigation on this subject is so important, and why the contributors to depression need to be identified. Several forms of depression treatments currently exist, including therapy and natural remedies, however the most common treatment form is antidepressants, more specifically those that include serotonin selective reuptake inhibitors (SSRIs), which work on the premise that depression is physically characterized by very low levels of serotonin transmission (Schafer, 1999). The level of serotonin transmission, or problems associated with this, changes with each individual, making for a large variation in success rates for antidepressants. Common forms of antidepressants therefore work by inhibiting reuptake molecules that aim to remove the mood enhancing neurotransmitter serotonin from the synapse (Daws, 2009). The success rate of these antidepressants has been declared quite sparse, particularly in cases of mild depression (Barbui & Garattini, 2006). These low levels of effectiveness encouraged further research on the subject. Studies commonly concluded that the cognitive or behavioural therapy is the most effective treatment for nearly all forms of depression (Simon, Pilling, Burbeck, & Goldberg, 2006). However, further investigation indicates that the combination of the of therapy and medication is the most effective on severe depressive symptoms (Fournier, DeRubeis, Shelton, Hollon, & Amsterdam, 2009). A study by Ekers, Richards and Gilbody (2007) found that cognitive or behavioural therapy, without the use of antidepressants, is effective due to the supportive counseling that patients receive during their treatment period. Psychological therapies such as these commonly target the dysfunctional attitudes associated with depression, including any negative assumptions that patients may use to judge themselves, such as associating the condition with weakness or inability to cope (Quilty, McBride, & Bagby, 2008). By targeting these negative attitudes and self assumptions, it is clear that their contribution to depression is substantial. Cognitive and behavioural therapy as a mean of treatment therefore supports the idea that external factors contribute to depression due to high success rates of a treatment that does not target biological aberrations. With an ever increasing rate of depression, contributing external factors, such as individual circumstances including stress, worry or anxiety, need to be identified so individuals can reach relief. The varied severity of symptoms for each patient often has an effect on individual perceptions about the contributing factors for their depression. As concluded by Budd, James and Hughes (2008), the most common reason that patients state as a contributor to their depression is a hormonal misbalance, followed closely by sexual assault or abuse. It should be noted however, that patients beliefs about what contributes to depression can produce a varied affect on treatment (Leykin, DeRubeis, Shelton, & Amsterdam, 2007), with many patients reacting positively to the doctor-patient relationship involved in behavioural therapy, potentially due to beliefs about contributing external factors, and expressing discontent towards antidepressant treatments, which can lead to substandard success rates (Chakraborty, Avasthi, Kumar, & Grover, 2009). Individual circumstances must be considered when determining the contributing factors to depression, such as common problems including stress, disease or personal misfortune. For example, it is well documented that major stress events often precede the onset of depression, including those whose symptoms are not considered to be a single depressive episode (Monroe & Reid, 2009). Perceptions and attitudes about depression and self, such as negative self assumptions, can also contribute to the condition (Quilty, McBride, & Bagby, 2008). For an illustration of how personal circumstances can contribute to depression, consider an individual under large amounts of stress, this coupled with pre existing negative self assumptions makes the proposal that they may be depressed reasonably credible. Much research also indicates that an individual’s coping ability can dramatically affect the onset of depression; with Van Horn (2002) declaring that promoting the competencies of those with mental health issues the key to improving a person’s coping abilities. This association between personal circumstances, including stress, varying coping abilities and anxiety, all external to biological makeup, is substantial in terms of isolating the particular aspects of individual circumstance that can contribute to depression. Looking further than personal circumstances to identify the aspects that contribute to depression, society and the economy can be considered, including antisocial behaviours that may exist in schools or the work place and political influences, socioeconomic status and social attitudes concerning depression. A study by Wight, Ko and Aneshensel (2011) found a distinct relationship between the societal characteristics of urban neighbourhoods, especially concerning socioeconomic status, and the onset of depression in middle age. The study concluded that, in particular, those at a socioeconomical disadvantage were more susceptible to depression, varying on an individual level. Furthermore, a larger variation in depression severity exists between younger middle aged individuals, with affects of race on depression being inconclusive (Wight et al., 2011). This study highlights how depression can stem from common circumstances, created by stress from a particular financial situation. Another common issue in society is individual’s problems with body image, a social norm that has developed in many western societies. A later study by Marsella, Shizuru, Brennan and Kameoka (1981) concluded that body image problems and depression interact in a complex way, where both depression and body issues extend to increasing negative self perceptions. The results of this study are supported by more recent findings that state the relationship between body image and depression is strong, particularly in young women (Sides-Moore & Tochkov, 2011). Societal issues such as negative body image perceptions and socioeconomics can directly link to antisocial behaviours whether in response or as a form of bullying, for example body image in schools. Links between antisocial behaviour and depression have been well established. A study by Rowe, Maughan and Eley (2006) explores the particular components of antisocial behaviour, including physical aggression, delinquency and oppositionality, with results that indicate that all but physical aggression associate with a depressed mood. Unfortunately societal issues such as negative self perceptions and antisocial behaviour are unlikely to disappear, and these factors, external to biological makeup, will continue to contribute to depression. Moving away from society, an entire culture also presents aspects which may contribute to depression, such as differences in religion and social norms. For example, it is a social norm for African American men to be inclined not to talk about their feelings, as it is seen to be a display of a lack of masculinity (Courtenay, 2000). Therefore, feelings of stress and worry may be internalized or manifest to the point that these feelings may contribute to depression (Courtenay, 2000). These differences in culture may also cause these young men to not seek treatment for their depression problems, exacerbating the severity of symptoms (Waite & Calamaro, 2009). These cultural differences and influences extend further to understanding depression and self. Studies indicate that different cultures encourage varying areas of self attention, for example, Chen, Guarnaccia, and Chung (2003) found that Asian men tend to focus more on the somatic aspects of self, and are far less likely than men of a western culture to acknowledge affective symptoms. This lack of awareness towards feelings and psychological wellbeing may lead to men of this particular culture to ignore depressive symptoms, encouraging the onset of depression, or even contributing to the severity of depression. Further study indicates that cross cultural differences can contribute to categorization of depressive symptoms. Lu, Bond, Friedman and Chan (2010) found that Chinese cultured individuals are far more likely than western cultured individuals (specifically, American) to objectify depressive symptoms, potentially effecting the likelihood of seeking treatment. Cultural differences therefore do not directly contribute to depression, however some social norms that differ from culture to culture can contribute to depression through lowering the likelihood for recognition of emotional problems, stress or worry for example, potentially leading to more severe affective symptoms. Considerable amounts of evidence presented here propose that factors external to the biological makeup of an individual contribute to depression in any form. Individual circumstances, particularly stress, undeniably contribute to a depressed mood (Monroe & Reid, 2009), and antisocial behaviours that exist in the lives of many further exacerbate depressive symptoms (Rowe, Maughan, & Eley, 2006). Economic, societal and cultural factors extend to the individual, encouraging certain values and norms, while providing further stress and worry over financial circumstances, can certainly give effect to how depression is perceived and treated. Furthermore, if consideration is made to certain research that declares depression does not even exist in parts of the world, the idea that these factors contribute to depression is undeniable (Schieffelin & Crittenden, 1993). Depression is an extremely complex condition, and isolating every aspect that contributes to its onset is a difficult task, nevertheless, it is clear that the factors discussed in this essay certainly contribute to depression, whether depression is mild or severe, or a single depressive episode. Treatments for depression now even include therapy sessions which target psychological attitudes and other self assumptions about depression. With large amounts of consistent evidence, it is clear that external factors to biological makeup, whether individual, cultural or societal, contribute to depression and it is by targeting these areas that individuals will receive relieve for their condition.