case study examples of depression

Mental Health Case Study: Understanding Depression through a Real-life Example

Imagine feeling an unrelenting heaviness weighing down on your chest. Every breath becomes a struggle as a cloud of sadness engulfs your every thought. Your energy levels plummet, leaving you physically and emotionally drained. This is the reality for millions of people worldwide who suffer from depression, a complex and debilitating mental health condition.

Understanding depression is crucial in order to provide effective support and treatment for those affected. While textbooks and research papers provide valuable insights, sometimes the best way to truly comprehend the depths of this condition is through real-life case studies. These stories bring depression to life, shedding light on its impact on individuals and society as a whole.

In this article, we will delve into the world of mental health case studies, using a real-life example to explore the intricacies of depression. We will examine the symptoms, prevalence, and consequences of this all-encompassing condition. Furthermore, we will discuss the significance of case studies in mental health research, including their ability to provide detailed information about individual experiences and contribute to the development of treatment strategies.

Through an in-depth analysis of a selected case study, we will gain insight into the journey of an individual facing depression. We will explore their background, symptoms, and initial diagnosis. Additionally, we will examine the various treatment options available and assess the effectiveness of the chosen approach.

By delving into this real-life example, we will not only gain a better understanding of depression as a mental health condition, but we will also uncover valuable lessons that can aid in the treatment and support of those who are affected. So, let us embark on this enlightening journey, using the power of case studies to bring understanding and empathy to those who need it most.

Understanding Depression

Depression is a complex and multifaceted mental health condition that affects millions of people worldwide. To comprehend the impact of depression, it is essential to explore its defining characteristics, prevalence, and consequences on individuals and society as a whole.

Defining depression and its symptoms

Depression is more than just feeling sad or experiencing a low mood. It is a serious mental health disorder characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities that were once enjoyable. Individuals with depression often experience a range of symptoms that can significantly impact their daily lives. These symptoms include:

1. Persistent feelings of sadness or emptiness. 2. Fatigue and decreased energy levels. 3. Significant changes in appetite and weight. 4. Difficulty concentrating or making decisions. 5. Insomnia or excessive sleep. 6. feelings of guilt, worthlessness, or hopelessness. 7. Loss of interest or pleasure in activities.

Exploring the prevalence of depression worldwide

Depression knows no boundaries and affects individuals from all walks of life. According to the World Health Organization (WHO), an estimated 264 million people globally suffer from depression. This makes depression one of the most common mental health conditions worldwide. Additionally, the WHO highlights that depression is more prevalent among females than males.

The impact of depression is not limited to individuals alone. It also has significant social and economic consequences. Depression can lead to impaired productivity, increased healthcare costs, and strain on relationships, contributing to a significant burden on families, communities, and society at large.

The impact of depression on individuals and society

Depression can have a profound and debilitating impact on individuals’ lives, affecting their physical, emotional, and social well-being. The persistent sadness and loss of interest can lead to difficulties in maintaining relationships, pursuing education or careers, and engaging in daily activities. Furthermore, depression increases the risk of developing other mental health conditions, such as anxiety disorders or substance abuse.

On a societal level, depression poses numerous challenges. The economic burden of depression is significant, with costs associated with treatment, reduced productivity, and premature death. Moreover, the social stigma surrounding mental health can impede individuals from seeking help and accessing appropriate support systems.

Understanding the prevalence and consequences of depression is crucial for policymakers, healthcare professionals, and individuals alike. By recognizing the significant impact depression has on individuals and society, appropriate resources and interventions can be developed to mitigate its effects and improve the overall well-being of those affected.

The Significance of Case Studies in Mental Health Research

Case studies play a vital role in mental health research, providing valuable insights into individual experiences and contributing to the development of effective treatment strategies. Let us explore why case studies are considered invaluable in understanding and addressing mental health conditions.

Why case studies are valuable in mental health research

Case studies offer a unique opportunity to examine mental health conditions within the real-life context of individuals. Unlike large-scale studies that focus on statistical data, case studies provide a detailed examination of specific cases, allowing researchers to delve into the complexities of a particular condition or treatment approach. This micro-level analysis helps researchers gain a deeper understanding of the nuances and intricacies involved.

The role of case studies in providing detailed information about individual experiences

Through case studies, researchers can capture rich narratives and delve into the lived experiences of individuals facing mental health challenges. These stories help to humanize the condition and provide valuable insights that go beyond a list of symptoms or diagnostic criteria. By understanding the unique experiences, thoughts, and emotions of individuals, researchers can develop a more comprehensive understanding of mental health conditions and tailor interventions accordingly.

How case studies contribute to the development of treatment strategies

Case studies form a vital foundation for the development of effective treatment strategies. By examining a specific case in detail, researchers can identify patterns, factors influencing treatment outcomes, and areas where intervention may be particularly effective. Moreover, case studies foster an iterative approach to treatment development—an ongoing cycle of using data and experience to refine and improve interventions.

By examining multiple case studies, researchers can identify common themes and trends, leading to the development of evidence-based guidelines and best practices. This allows healthcare professionals to provide more targeted and personalized support to individuals facing mental health conditions.

Furthermore, case studies can shed light on potential limitations or challenges in existing treatment approaches. By thoroughly analyzing different cases, researchers can identify gaps in current treatments and focus on areas that require further exploration and innovation.

In summary, case studies are a vital component of mental health research, offering detailed insights into the lived experiences of individuals with mental health conditions. They provide a rich understanding of the complexities of these conditions and contribute to the development of effective treatment strategies. By leveraging the power of case studies, researchers can move closer to improving the lives of individuals facing mental health challenges.

Examining a Real-life Case Study of Depression

In order to gain a deeper understanding of depression, let us now turn our attention to a real-life case study. By exploring the journey of an individual navigating through depression, we can gain valuable insights into the complexities and challenges associated with this mental health condition.

Introduction to the selected case study

In this case study, we will focus on Jane, a 32-year-old woman who has been struggling with depression for the past two years. Jane’s case offers a compelling narrative that highlights the various aspects of depression, including its onset, symptoms, and the treatment journey.

Background information on the individual facing depression

Before the onset of depression, Jane led a fulfilling and successful life. She had a promising career, a supportive network of friends and family, and engaged in hobbies that brought her joy. However, a series of life stressors, including a demanding job, a breakup, and the loss of a loved one, began to take a toll on her mental well-being.

Jane’s background highlights a common phenomenon – depression can affect individuals from all walks of life, irrespective of their socio-economic status, age, or external circumstances. It serves as a reminder that no one is immune to mental health challenges.

Presentation of symptoms and initial diagnosis

Jane began noticing a shift in her mood, characterized by persistent feelings of sadness and a lack of interest in activities she once enjoyed. She experienced disruptions in her sleep patterns, appetite changes, and a general sense of hopelessness. Recognizing the severity of her symptoms, Jane sought help from a mental health professional who diagnosed her with major depressive disorder.

Jane’s case exemplifies the varied and complex symptoms associated with depression. While individuals may exhibit overlapping symptoms, the intensity and manifestation of those symptoms can vary greatly, underscoring the importance of personalized and tailored treatment approaches.

By examining this real-life case study of depression, we can gain an empathetic understanding of the challenges faced by individuals experiencing this mental health condition. Through Jane’s journey, we will uncover the treatment options available for depression and analyze the effectiveness of the chosen approach. The case study will allow us to explore the nuances of depression and provide valuable insights into the treatment landscape for this prevalent mental health condition.

The Treatment Journey

When it comes to treating depression, there are various options available, ranging from therapy to medication. In this section, we will provide an overview of the treatment options for depression and analyze the treatment plan implemented in the real-life case study.

Overview of the treatment options available for depression

Treatment for depression typically involves a combination of approaches tailored to the individual’s needs. The two primary treatment modalities for depression are psychotherapy (talk therapy) and medication. Psychotherapy aims to help individuals explore their thoughts, emotions, and behaviors, while medication can help alleviate symptoms by restoring chemical imbalances in the brain.

Common forms of psychotherapy used in the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and psychodynamic therapy. These therapeutic approaches focus on addressing negative thought patterns, improving relationship dynamics, and gaining insight into underlying psychological factors contributing to depression.

In cases where medication is utilized, selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed. These medications help rebalance serotonin levels in the brain, which are often disrupted in individuals with depression. Other classes of antidepressant medications, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs), may be considered in specific cases.

Exploring the treatment plan implemented in the case study

In Jane’s case, a comprehensive treatment plan was developed with the intention of addressing her specific needs and symptoms. Recognizing the severity of her depression, Jane’s healthcare team recommended a combination of talk therapy and medication.

Jane began attending weekly sessions of cognitive-behavioral therapy (CBT) with a licensed therapist. This form of therapy aimed to help Jane identify and challenge negative thought patterns, develop coping strategies, and cultivate more adaptive behaviors. The therapeutic relationship provided Jane with a safe space to explore and process her emotions, ultimately helping her regain a sense of control over her life.

In conjunction with therapy, Jane’s healthcare provider prescribed an SSRI medication to assist in managing her symptoms. The medication was carefully selected based on Jane’s specific symptoms and medical history, and regular follow-up appointments were scheduled to monitor her response to the medication and adjust the dosage if necessary.

Analyzing the effectiveness of the treatment approach

The effectiveness of treatment for depression varies from person to person, and it often requires a period of trial and adjustment to find the most suitable intervention. In Jane’s case, the combination of cognitive-behavioral therapy and medication proved to be beneficial. Over time, she reported a reduction in her depressive symptoms, an improvement in her overall mood, and increased ability to engage in activities she once enjoyed.

It is important to note that the treatment journey for depression is not always linear, and setbacks and challenges may occur along the way. Each individual responds differently to treatment, and adjustments might be necessary to optimize outcomes. Continuous communication between the individual and their healthcare team is crucial to addressing any concerns, monitoring progress, and adapting the treatment plan as needed.

By analyzing the treatment approach in the real-life case study, we gain insights into the various treatment options available for depression and how they can be tailored to meet individual needs. The combination of psychotherapy and medication offers a holistic approach, addressing both psychological and biological aspects of depression.

The Outcome and Lessons Learned

After undergoing treatment for depression, it is essential to assess the outcome and draw valuable lessons from the case study. In this section, we will discuss the progress made by the individual in the case study, examine the challenges faced during the treatment process, and identify key lessons learned.

Discussing the progress made by the individual in the case study

Throughout the treatment process, Jane experienced significant progress in managing her depression. She reported a reduction in depressive symptoms, improved mood, and a renewed sense of hope and purpose in her life. Jane’s active participation in therapy, combined with the appropriate use of medication, played a crucial role in her progress.

Furthermore, Jane’s support network of family and friends played a significant role in her recovery. Their understanding, empathy, and support provided a solid foundation for her journey towards improved mental well-being. This highlights the importance of social support in the treatment and management of depression.

Examining the challenges faced during the treatment process

Despite the progress made, Jane faced several challenges during her treatment journey. Adhering to the treatment plan consistently proved to be difficult at times, as she encountered setbacks and moments of self-doubt. Additionally, managing the side effects of the medication required careful monitoring and adjustments to find the right balance.

Moreover, the stigma associated with mental health continued to be a challenge for Jane. Overcoming societal misconceptions and seeking help required courage and resilience. The case study underscores the need for increased awareness, education, and advocacy to address the stigma surrounding mental health conditions.

Identifying the key lessons learned from the case study

The case study offers valuable lessons that can inform the treatment and support of individuals with depression:

1. Holistic Approach: The combination of psychotherapy and medication proved to be effective in addressing the psychological and biological aspects of depression. This highlights the need for a holistic and personalized treatment approach.

2. Importance of Support: Having a strong support system can significantly impact an individual’s ability to navigate through depression. Family, friends, and healthcare professionals play a vital role in providing empathy, understanding, and encouragement.

3. Individualized Treatment: Depression manifests differently in each individual, emphasizing the importance of tailoring treatment plans to meet individual needs. Personalized interventions are more likely to lead to positive outcomes.

4. Overcoming Stigma: Addressing the stigma associated with mental health conditions is crucial for individuals to seek timely help and access the support they need. Educating society about mental health is essential to create a more supportive and inclusive environment.

By drawing lessons from this real-life case study, we gain insights that can improve the understanding and treatment of depression. Recognizing the progress made, understanding the challenges faced, and implementing the lessons learned can contribute to more effective interventions and support systems for individuals facing depression.In conclusion, this article has explored the significance of mental health case studies in understanding and addressing depression, focusing on a real-life example. By delving into case studies, we gain a deeper appreciation for the complexities of depression and the profound impact it has on individuals and society.

Through our examination of the selected case study, we have learned valuable lessons about the nature of depression and its treatment. We have seen how the combination of psychotherapy and medication can provide a holistic approach, addressing both psychological and biological factors. Furthermore, the importance of social support and the role of a strong network in an individual’s recovery journey cannot be overstated.

Additionally, we have identified challenges faced during the treatment process, such as adherence to the treatment plan and managing medication side effects. These challenges highlight the need for ongoing monitoring, adjustments, and open communication between individuals and their healthcare providers.

The case study has also emphasized the impact of stigma on individuals seeking help for depression. Addressing societal misconceptions and promoting mental health awareness is essential to create a more supportive environment for those affected by depression and other mental health conditions.

Overall, this article reinforces the significance of case studies in advancing our understanding of mental health conditions and developing effective treatment strategies. Through real-life examples, we gain a more comprehensive and empathetic perspective on depression, enabling us to provide better support and care for individuals facing this mental health challenge.

As we conclude, it is crucial to emphasize the importance of continued research and exploration of mental health case studies. The more we learn from individual experiences, the better equipped we become to address the diverse needs of those affected by mental health conditions. By fostering a culture of understanding, support, and advocacy, we can strive towards a future where individuals with depression receive the care and compassion they deserve.

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Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

151 Case Studies: Real Stories Of People Overcoming Struggles of Mental Health

At Tracking Happiness, we’re dedicated to helping others around the world overcome struggles of mental health.

In 2022, we published a survey of 5,521 respondents and found:

• 88% of our respondents experienced mental health issues in the past year.
• 25% of people don’t feel comfortable sharing their struggles with anyone, not even their closest friends.

In order to break the stigma that surrounds mental health struggles, we’re looking to share your stories.

Overcoming struggles

They say that everyone you meet is engaged in a great struggle. No matter how well someone manages to hide it, there’s always something to overcome, a struggle to deal with, an obstacle to climb.

And when someone is engaged in a struggle, that person is looking for others to join him. Because we, as human beings, don’t thrive when we feel alone in facing a struggle.

Let’s throw rocks together

Overcoming your struggles is like defeating an angry giant. You try to throw rocks at it, but how much damage is one little rock gonna do?

Tracking Happiness can become your partner in facing this giant. We are on a mission to share all your stories of overcoming mental health struggles. By doing so, we want to help inspire you to overcome the things that you’re struggling with, while also breaking the stigma of mental health.

Which explains the phrase: “Let’s throw rocks together”.

Let’s throw rocks together, and become better at overcoming our struggles collectively. If you’re interested in becoming a part of this and sharing your story, click this link!

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Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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A Systematic Review of Grief and Depression in Adults

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Although grief is a normal response to loss, it is a complex and multidimensional process that can involve a wide range of distressing symptoms and significantly affect an individual’s functioning. People respond to death in diverse ways, both adaptively and maladaptively, and these reactions are highly personalized. During this time, bereaved individuals engage in tasks such as accepting the reality of the loss, managing emotional distress, adjusting to life without the deceased, and eventually letting go of the emotional attachment to the person who has died.

• This systematic review synthesized findings on depression and grief in adults, aiming to identify specificities of depression in grief and whether grief varies based on the type of loss.
• Factors like gender, education level, socioeconomic status, age of the deceased, cause of death, and time since loss significantly affect grief outcomes and the development of depression.
• The research, while enlightening, has limitations, such as the inability to isolate depression from other grief symptoms in some studies and variation in the types of losses examined.
• Understanding the relationship between grief and depression is universally relevant, as most people will experience the loss of a loved one and may be at risk for negative mental health outcomes.

Grief is a profound life experience that can lead to complications like depression for bereaved individuals. Depressive symptoms place a heavy burden on societal resources (Moreira et al., 2023).

Previous research has shown significant overlap between grief and depression in terms of symptoms, characteristics, family history, and response to medication (Kendler et al., 2008; Lamb et al., 2010; Zisook & Kendler, 2007; Zisook et al., 2001, 2007).

Increasing evidence indicates losing a loved one can lead to prolonged grief disorder and depressive symptoms/syndromes (Bonanno et al., 2007; Prigerson et al., 2009; Shear et al., 2011).

This systematic review aimed to synthesize findings on depression and grief to identify specificities of depression in grief and factors influencing grief outcomes.

Understanding the distinctions between grief and depression has important implications for the mental and physical health of bereaved individuals.

This systematic review followed PRISMA guidelines. Studies were identified through searching EBSCO, PubMed, and Web of Science databases.

• Search terms included variations of “depression,” “grief,” “bereavement,” and “mourning.”
• Inclusion criteria were having a grief sample and depression measures.
• Exclusion criteria included case studies, theoretical essays, reviews, instrument validations, not examining grief and depression, non-bereaved samples, and low study quality.

41 studies published between 1939-2021 were included. Two independent reviewers selected studies with almost perfect agreement (Cohen’s κ = .86). Study quality was assessed with the Quantitative Research Assessment Tool.

The search equation used variations of the key terms in the databases:

• EBSCO: TI (depress* OR mood disorder) AND TI (mourn* OR grief OR bereave* OR death OR loss)
• PubMed: (depress [Title] OR mood disorder[Title]) AND (mourn [Title] OR grief[Title] OR bereave* OR death[Title] OR loss)
• Web of Science: TI=(depress* OR mood disorder) AND TI=(mourn* OR grief OR bereave* OR death OR loss)

Studies can be grouped into two categories based on time of loss, namely grief during pregnancy or grief of a close relative

• After spontaneous abortion, women experienced more grief and depressive symptoms than their male partners. Childless women and those with infertility had higher grief.
• After miscarriage, 26.6% of women who met grief criteria also had depressive episodes.
• Grief symptoms decreased over a year after pregnancy loss, but depressive symptoms increased around 6 months for women who experienced sudden losses.
• Negative cognitions predicted grief 16-19 months after a perinatal death. Having more children was associated with less depression.

Early Childhood

• Infant death was associated with increased depression and psychosis-like experiences in mothers.
• 34% of caregivers had clinically significant depressive symptoms 3 months after losing a loved one.

Childhood/Adolescence

• 30% of bereaved parents had depression 5 years after a child’s cancer death vs. 14% of parents whose child survived. Mothers had more depression than fathers.
• Parental grief was predicted more by couple-level factors while depression was predicted more by individual factors. Traumatic child deaths led to more parental grief.

Adults/Elderly

• In gay men who lost a friend to AIDS, grief and depression were distinct. Depression was predicted by negative affect, health concerns, and loneliness. Grief was predicted by number of AIDS losses.
• 16% met criteria for complicated grief (CG) 1-2 years after losing a friend/relative. Relationship depth predicted CG while dependence predicted depression.
• Pre-loss grief, being a partner, and low education predicted post-loss CG and depression in caregivers.
• Violent deaths led to more depression, especially in females. CG and depression decreased over time after loss. More years since loss was associated with less depression in elders.

This review provides insights into the complex relationship between grief and depression after different types of losses.

While there is overlap, they emerge as distinct responses – certain factors uniquely predict grief (e.g., relationship depth, couple-level factors), while others uniquely predict depression (e.g., personal vulnerabilities, less time since loss).

Gender, education level, socioeconomic status, age of the deceased, cause of death, and time since loss are significant factors that influence grief outcomes and the development of depression following bereavement.

Research has shown that women often experience more intense grief and depressive symptoms compared to men, particularly in cases of miscarriage or child loss. Lower levels of education and socioeconomic status have been associated with a higher risk of complicated grief and difficulty coping with loss.

The age of the deceased also plays a role, with the loss of a child or younger individual often leading to more severe grief reactions compared to the loss of an older person.

Sudden, traumatic, or violent causes of death, such as accidents, homicide, or suicide, can result in more complicated grief and depression compared to losses due to natural causes or prolonged illness.

Finally, the time elapsed since the loss is a significant factor, as grief and depressive symptoms tend to decrease over time as individuals adjust to their new reality.

However, for some, grief may remain intense and prolonged, leading to complicated grief or persistent depression. Understanding these factors can help identify individuals at higher risk for adverse grief outcomes and inform targeted interventions.

Future research could further examine how the predictors of grief and depression vary depending on kinship to the deceased and expand to include more diverse causes of death.

• Followed PRISMA guidelines for systematic reviews
• Broad search of multiple databases
• Rigorous inclusion/exclusion criteria
• Independent reviewer selection of studies with high inter-rater reliability
• Assessed study quality with a standardized tool
• Examined grief and depression in response to various types of losses across the lifespan

Limitations

• Some included studies could not statistically isolate depression from other grief symptoms
• High variability in the types of losses and kinship of bereaved individuals across studies
• Conclusions may be limited by the demographics of study samples and countries where research was conducted
• Cross-sectional and retrospective designs of some studies prevent causal conclusions

Clinical Implications

The results have significant real-world implications, especially for clinical practice.

Understanding risk factors for intense, prolonged grief and depression can help practitioners identify bereaved clients who may need more support.

For example, those with prior depression/mental health issues, traumatic losses, or fewer coping resources may be more vulnerable.

Screening for complicated grief (CG) is important since it is underpinned more by interpersonal factors and may not respond to depression treatments.

Distinguishing between grief and depression is important for intervention and treatment, as grief is a normal response while depression may be more likely in individuals with certain vulnerabilities. However, some individuals with vulnerabilities may have a decreased ability to grieve.

The findings also suggest value in dyadic and family interventions since couple/family dynamics can influence grief. Gender differences imply the potential benefits of tailoring treatments.

Broadly, the review underscores the need to recognize the long-term impacts of bereavement, as grief and depressive symptoms can persist for years. Societal resources should be allocated to make bereavement support accessible.

More public education on the range of normal grief responses may help destigmatize the grief experience.

Primary reference

Moreira, D., Azeredo, A., Moreira, D. S., Fávero, M., & Sousa-Gomes, V. (2022). Why Does Grief Hurt?.  European Psychologist, 28 (1), 35–52. https://doi.org/10.1027/1016-9040/a000490

Other references

Bonanno, G. A., Neria, Y., Mancini, A., Coifman, K. G., Litz, B., & Insel, B. (2007). Is there more to complicated grief than depression and posttraumatic stress disorder? A test of incremental validity. Journal of Abnormal Psychology, 116 (2), 342–351. https://doi.org/10.1037/0021-843x.116.2.342

Kendler, K. S., Myers, J., & Zisook, S. (2008). Does bereavement-related major depression differ from major depression associated with other stressful life events? American Journal of Psychiatry, 165 (11), 1449-1455. https://doi.org/10.1176/appi.ajp.2008.07111757

Lamb, K., Pies, R., & Zisook, S. (2010). The bereavement exclusion for the diagnosis of major depression: To be or not to be. Psychiatry, 7 (7), 19-25.

Moreira, D., Azeredo, A., Moreira, D.S., Fávero, M., & Sousa-Gomes, V. (2023). Why does grief hurt? A systematic review of grief and depression in adults. European Psychologist, 28 (1), 35-52. https://doi.org/10.1027/1016-9040/a000490

Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., Raphael, B., Marwit, S. J., Wortman, C., Neimeyer, R. A., Bonanno, G. A., Block, S. D., Kissane, D., Boelen, P., Maercker, A., Litz, B. T., Johnson, J. G., First, M. B., & Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6 (8), Article e1000121. https://doi.org/10.1371/journal.pmed.1000121

Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., Reynolds, C., Lebowitz, B., Sung, S., Ghesquiere, A., Gorscak, B., Clayton, P., Ito, M., Nakajima, S., Konishi, T., Melhem, N., Meert, K., Schiff, M., O’Connor, M., … Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28 (2), 103–117. https://doi.org/10.1002/da.20780

Zisook, S., & Kendler, K. S. (2007). Is bereavement-related depression different than non-bereavement-related depression?. Psychological Medicine, 37 (6), 779-794. https://doi.org/10.1017/S0033291707009865

Zisook, S., Shuchter, S. R., Pedrelli, P., Sable, J., & Deaciuc, S. C. (2001). Bupropion sustained release for bereavement: Results of an open trial. Journal of Clinical Psychiatry, 62 (4), 227-230. https://doi.org/10.4088/jcp.v62n0403

Zisook, S., Shear, K., & Kendler, K. S. (2007). Validity of the bereavement exclusion criterion for the diagnosis of major depressive episode. World Psychiatry, 6 (2), 102-107.

Keep Learning

• What factors do you think might influence how an individual responds to and copes with the death of a loved one? How could cultural background play a role?
• This review found some gender differences in grief and depression. Why do you think men and women may respond differently to loss? What are the implications for providing support?
• Imagine someone close to you experienced a significant loss one year ago. Based on the findings, what signs might indicate they are struggling with complicated grief and could benefit from professional help?
• The results suggest grief and depression are distinct but overlapping responses. How would you explain the difference between grief and depression to a friend who recently lost a loved one?
• Many of the studies used self-report measures of grief and depression symptoms. What are the strengths and limitations of this type of data? What other methods could provide useful insights?
• No single theory can fully explain the range of grief responses. What are some different theoretical perspectives on the grieving process? How could integrating them help us better understand the complexity of coping with loss?

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A New Study Is Finally Attempting to Pin Down The Root Causes of Depression

Most experts agree that depression is not one thing.

The core experiences of depression — changes in energy, activity, thinking, and mood — have been described for more than 10,000 years. The word “depression” has been used for about 350 years.

Given this long history, it may surprise you that experts don’t agree about what depression is, how to define it, or what causes it.

However, many experts do agree that depression is not one thing . It’s a large family of illnesses with different causes and mechanisms. This makes choosing the best treatment for each person challenging.

Reactive vs endogenous depression

One strategy is to search for sub-types of depression and see whether they might do better with different kinds of treatments. One example is contrasting “reactive” depression with “endogenous” depression.

Reactive depression (also thought of as social or psychological depression) is presented as being triggered by exposure to stressful life events. These might be being assaulted or losing a loved one — an understandable reaction to an outside trigger.

Endogenous depression (also thought of as biological or genetic depression) is proposed to be caused by something inside , such as genes or brain chemistry.

Many people working clinically in mental health accept this sub-typing. You might have read about this online .

But we think this approach is way too simple.

While stressful life events and genes may, individually, contribute to causing depression, they also interact to increase the risk of someone developing depression. And evidence shows that there is a genetic component to being exposed to stressors. Some genes affect things such as personality. Some affect how we interact with our environments.

What we did and what we found

Our team set out to look at the role of genes and stressors to see if classifying depression as reactive or endogenous was valid.

In the Australian Genetics of Depression Study , people with depression answered surveys about exposure to stressful life events. We analyzed DNA from their saliva samples to calculate their genetic risk for mental disorders.

Our question was simple. Does genetic risk for depression, bipolar disorder, schizophrenia, ADHD, anxiety, and neuroticism (a personality trait) influence people’s reported exposure to stressful life events?

You may be wondering why we bothered calculating the genetic risk for mental disorders in people who already have depression. Every person has genetic variants linked to mental disorders. Some people have more, some less. Even people who already have depression might have a low genetic risk for it. These people may have developed their particular depression from some other constellation of causes.

We looked at the genetic risk of conditions other than depression for a couple of reasons. First, genetic variants linked to depression overlap with those linked to other mental disorders. Second, two people with depression may have completely different genetic variants. So, we wanted to cast a wide net to look at a wider spectrum of genetic variants linked to mental disorders.

If reactive and endogenous depression sub-types are valid, we’d expect people with a lower genetic component to their depression (the reactive group) to report more stressful life events. And we’d expect those with a higher genetic component (the endogenous group) would report fewer stressful life events.

But after studying more than 14,000 people with depression, we found the opposite.

We found people at higher genetic risk for depression, anxiety, ADHD, or schizophrenia say they’ve been exposed to more stressors .

Assault with a weapon, sexual assault, accidents, legal and financial troubles, and childhood abuse and neglect were all more common in people with a higher genetic risk of depression, anxiety, ADHD, or schizophrenia.

These associations were not strongly influenced by people’s age, sex, or relationships with family. We didn’t look at other factors that may influence these associations, such as socioeconomic status. We also relied on people’s memory of past events, which may not be accurate.

How do genes play a role?

Genetic risk for mental disorders changes people’s sensitivity to the environment.

Imagine two people, one with a high genetic risk for depression and one with a low risk. They both lose their jobs. The genetically vulnerable person experiences the job loss as a threat to their self-worth and social status. There is a sense of shame and despair. They can’t bring themselves to look for another job for fear of losing it, too. For the other, the job loss feels less about them and more about the company. These two people internalize the event differently and remember it differently.

Genetic risk for mental disorders also might make it more likely people find themselves in environments where bad things happen. For example, a higher genetic risk for depression might affect self-worth, making people more likely to get into dysfunctional relationships, which then go badly.

What does our study mean for depression?

First, it confirms genes and environments are not independent. Genes influence the environments we end up in and what then happens. Genes also influence how we react to those events.

Second, our study doesn’t support a distinction between reactive and endogenous depression. Genes and environments have a complex interplay. Most cases of depression are a mix of genetics, biology, and stressors.

Third, people with depression who appear to have a stronger genetic component to their depression report their lives are punctuated by more serious stressors.

So, clinically, people with higher genetic vulnerability might benefit from learning specific techniques to manage their stress. This might help some people reduce their chance of developing depression in the first place. It might also help some people with depression reduce their ongoing exposure to stressors.

This article was originally published on The Conversation by Jacob Crouse and Ian Hickie at the University of Sydney . Read the original article here .

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Cognitive group therapy for depressive students: The case study

Juhani tiuraniemi.

University of Turku, Department of Psychology, University of Turku, Finland

Jarno Korhola

The aims of this study were to assess whether a course of cognitive group therapy could help depressed students and to assess whether assimilation analysis offers a useful way of analysing students' progress through therapy. “Johanna” was a patient in a group that was designed for depressive students who had difficulties with their studies. The assimilation of Johanna's problematic experience progressed as the meetings continued from level one (unpleasant thoughts) to level six (solving the problem). Johanna's problematic experience manifested itself as severe and excessive criticism towards herself and her study performance. As the group meetings progressed, Johanna found a new kind of tolerance that increased her determination and assertiveness regarding the studies. The dialogical structure of Johanna's problematic experience changed: she found hope and she was more assertive after the process. The results indicated that this kind of psycho-educational group therapy was an effective method for treating depression. The assimilation analysis offered a useful way of analysing the therapy process.

Introduction

Clinical depression is one of the most common mental disorders (Kessler, Berglund, Demler et al., 2003 ). Approximately 5–6% of Finns suffer from depression (Isometsä, 2001 ; Isometsä, Aro & Aro, 1997). Students suffering from depression often have difficulties in coping with their studies (Brackney & Karabenick, 1995 ; Kessler & Walters, 1998 ; Lyubomirsky, Kasri & Zehm, 2003 ), and a strong association has been found between depressive symptoms and stress (Mikolajczyk, Maxwell, Naydenova, Meier & Ansari, 2008 ). According to their own estimation, 53% of American college students had suffered from depression during their studies (Furr, Westefeld, McConnell & Jenkins, 2001 ). Over half of those who had experienced depression stated that problems related to studying were the most important depression-inducing factor. Therefore, there is a close connection between depression and studying difficulties.

According to Isometsä et al. ( 1997 ), of those who suffer from depression, 50% feel they need mental health services. Of depressed students, 17% seek help for their problems (Furr et al., 2001 ). Depression diminishes a person's ability to act through various mechanisms. Being depressed has a lowering effect on a student's sense of self-efficacy (Beck, 1976 ) and it lowers the expectations of doing well with one's studies (Brackney & Karabenick, 1995 ). A depressed student may feel that he/she will not complete his/her studies like everyone else. The fatigue, the powerlessness and the lack of concentration that accompany depression also reduce the student's ability to function.

Depression affects academic performance and ability to act through the students' motivation and their use of studying strategies (Brackney & Karabenick, 1995 ; Lyubomirsky et al., 2008). Often, depressed students are not able to plan their studies efficiently or observe their own work. They may have difficulties in sufficiently regulating their time-use, their study environment or the amount of work they pour into their tasks. Cognitive-behavioural therapy resulted in a significant improvement in perceived stress, depressive symptoms, reduced use of avoidance coping strategies, and more use of approach coping strategies among university students (Hamdan-Mansour, Puskar & Bandak, 2009 ).

Persons with depressive symptoms often seek validation for their own needs and actions from other people (Clark & Beck, 1999 ). In this manner, they strive to prove their worth, their competence or their likeableness. Those suffering from depression often have limited social skills (Segrin, 2000 ). This leaves a student in an adverse position, because there is an inseparable social side to student life.

Sometimes a depressive person is troubled by the aspiration to be extremely competent and efficient. Perfectionist tendencies involve high expectations of oneself, and an individual's self-respect is based on the perception of one's own efficiency and competence (Chang & Sanna, 2001 ; Cox & Enns, 2003 ). Perfectionists have difficulty working with others and find asking for help very difficult (Brackney & Karabenick, 1995 ). In a student, high expectations of competence may be manifested as, for example, a great amount of work done, good marks and dissatisfaction with a performance that did not reach the desired level and is not consistent with one's self-image.

There has been quite a lot of research on the effects of cognitive-behavioural group therapy as a treatment for depression. According to the extensive mapping by DeRubeis and Crits-Christoph ( 1998 ), treating depression with cognitive-behavioural group therapy is efficient and useful. Kush and Fleming ( 2000 ) have had similar results. In their therapy, they tried to teach the patients skills that diminish depression and anxiety. For example, they tried to develop the patients' problem-solving skills. Treating depression with cognitive-behavioural group therapy has proven efficient and useful (Bright, Baker & Neimeyer, 1999 ; DeRubeis & Crits-Christoph, 1998 ; Kush & Fleming, 2000 ; Kwon & Oei, 2003 ). Cognitive behavioural group therapy has led to reduction in the levels of depression, negative automatic thoughts, and students' dysfunctional attitudes (Hamamci, 2006 ). It has been proven that the symptoms of depression lessen during therapy.

Brackney and Karabenick ( 1995 ) stated that psychotherapy aimed at students suffering from depression should contain instruction on structuring one's studies and on life-control skills . The patients should also be taught means of mood-control to improve their concentration and they should be encouraged not to ruminate and wallow in their depression (Lam, Smith, Checkley, Rijsdijk & Sham, 2003 ). Certain group-members' individual factors can predict their benefit from group therapy: mild depression in the beginning of the group work, a feeling of being in control of the situation, the group's cohesiveness and the ability to function as a group (Hoberman, Lewinsohn & Tilson, 1988 ). According to Pace and Dixon ( 1993 ), short-lived cognitive therapy lessens the depressive symptoms and also helps the schemata related to a more positive self-image.

Greenberg ( 2002 ) has stated that the change happens by activating an unadaptive schema to which an adaptive feeling is then attached. For instance, an unadaptive schema created by loss can be changed by grieving, that is, by adding the feeling of grief to the schema. According to Guidano ( 1991 ), the superficial and deep level change-processes do not exclude each other; in fact, superficial changes may promote deep level changes. In the assimilation model (for example Stiles, 2002 ; Stiles et al., 1990 ; Stiles et al., 1991 ), the change occurs by the assimilation of problematic experiences into a particular schema or schema chart. This can be described in eight different stages.

The change has been described in stage theories. The transtheoretical model posits that health behaviour change involves progression through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska & Velicer, 1997 ). Precontemplation is the stage wherein individuals are not aware of their problems, and they are resistant to change. In the contemplation stage, they are aware of their troubled behaviour but they are not committed to action. In the action stage, they change their behaviour and in the maintenance stage they try to prevent relapse. The assimilation model is more detailed and the description of cognitions and emotions is more specific. With the aid of the assimilation analysis, it is possible to delve into the cognitive and emotional changes that occur in the patient's problematic experiences and to evaluate the change process. The analysis is not just about the final result of the therapy: the problematic experience and the stages of changes the individual goes through are observed and assessed at different phases of therapy (Stiles et al., 1990 , 1991 ; Stiles & Osatuke, 2000 ).

A series of case studies has been executed using assimilation analysis (e.g. Brinegar, Salvi, Stiles, & Greenberg, 2006 ; Leiman & Stiles, 2001 ; Stiles et al., 2006 ). Assimilation analysis allows for focus on the focal points of the process. Using a case study has some advantages, e.g. the possibility to describe detailed process in psychotherapy, but there are some limitations. Behaviour can be described, not explained, and a case study cannot be representative of the general group or population. However, there is a need for process descriptions when we want to find a means to help depressive students who have problems in their studies. The evaluation of the case can also be susceptible to mistakes. For example, the researcher can see the change more positively or in the perception that other psychological phenomena can happen. In the evaluation, one must indeed be conscious of this , and be able to change a perspective for a subject so that mistakes in the evaluation do not take place (Montgomery & Willen, 1999 ).

This study depicts the change process of a student's psyche. The aims were to assess whether a course of cognitive group therapy could help depressed students with their problems affecting their studies and to assess whether assimilation analysis offers a useful way of analysing students' progress through therapy. This study was carried out using assimilation analysis to try to interpret and understand the contents of the subject's problematic experiences and the change she underwent through the sessions.

Research methods

The basic materials of this study are Johanna's (the name has been changed) discussion contributions that were singled out from taped group sessions. Johanna is a university student suffering from depression.

The group consisted of six students suffering from depression and studying difficulties. Altogether, the group met 16 times and the sessions lasted two hours each. In its final form, the group was composed of five women and one man. One student stopped attending the course after four times. The members' ages varied from just over 20 to a little over 40 years of age. Five of the members were at the final stages of their studies, and one was at the beginning of them. Some students were receiving treatment elsewhere, but we had no exact information about other care or treatment. Those who were at the final stages of their studies had particular difficulties with their theses and their studies had been delayed. The research subjects were referred to take part in the course and in this research by the Turku branch of Finnish Students Health Service (FSHS).

In the beginning of the course, the goal was to activate the participants. At a later stage, more attention was paid to the feelings of helplessness and powerlessness and how these feelings affected the participants' studying performance. The contents of the group sessions and the themes covered in each of them are depicted in Table I . In the beginning of the course, students made exercises in problem-solving methods. The basic elements in cognitive therapy are behaviour techniques, methods for studying beliefs and thoughts and techniques for managing emotions and feelings. The students analysed the things that hinder their studies and goals. After that, they analysed their daily activities and planned new strategies for their actions and studies. They analysed the effect of thought and worked with their beliefs and thoughts. They made assertiveness exercises and learned new strategies for managing their emotions. At the end of the course, they evaluated what they had learned and what they have to do in the future.

Cognitive group therapy for depressive students: Course program and contents.

The criteria for participating in the course were: (1) depression (at least 13 points on the BDI-scale); and (2) constant absences from lectures or delay of studies. It was stipulated that suicide risk, bidirectional affective syndrome and acute crisis would prevent participation in the course. In addition, it was expected of the attendees that they possess enough concentration to carry out the assignments required by the course programme.

The preliminary interviews were conducted to assess who could benefit from this short-term, psycho-educative course. To have successful group therapy, preliminary interviews and the composition of the group have to be carried out with utmost care (Bernard et al., 2008 ). The group meetings were referred to as a course instead of group therapy, because its purpose was to be as non-labelling and as easily approachable as possible. The interviews and the composing of the group were conducted by the group leader.

The course consisted mainly of different assignments that the participants completed on their own time. At the sessions, the group leader led discussion about the assignments. The participants were given assignments such as mapping out their social network and thinking about problems that complicated their studies. The assignments were based on a book of exercises called Depressiokoulu (Depression School) by Koffert and Kuusi ( 2003 ). The depression school introduced in the book consists of ten lessons that were used in the course when planning the 16-session programme. The group leader's role was active and encouraging.

The therapist had six years of therapy education in cognitive therapy, and six years of education in family therapy. Furthermore, he had experience from working with the groups. The supervisor had qualifications of the trainer psychotherapist (cognitive therapy) and the work supervision was carried out during the group process.

The case discussed in this study was chosen on the criteria of informativeness and representativeness compared to other group members. Johanna (the name has been changed) was a university student suffering from depression. At the beginning of the course, Johanna was just under 30 years of age and living with her significant other. She was a student of natural sciences and her studies were at the stage where she was to write her thesis.

Johanna's studies had been stuck for 18 months. Carrying out the studies seemed utterly overpowering to her. She had found other things to do instead of studying, such as household chores. Johanna felt that she no longer had any ambition to study and in addition, her motivation to study her chosen field was running low. This was, at least in part, due to the lack of jobs in the field.

Johanna felt that she had fallen hopelessly behind from her fellow students. She avoided meeting her course mates and spoke to virtually no one about her studying difficulties. She said that she lacked concentration. Johanna felt she was lazy and inefficient. She described herself as bad and a failure, both as a student and as a person. She had worked during the summers and the work had gone well.

Depression represents a mode that has been named loss or deprivation mode (Clark & Beck, 1999 ). There were indications of each of the schemata included in the mode in Johanna. In Johanna's case, feelings of hopelessness and the loss of pleasurable feelings (motivational scheme) were particularly noticeable, in addition to passiveness and withdrawal (behavioural scheme). Johanna felt dispirited (affective scheme) and she had difficulty in coping with her studies (physiological scheme). The threat of loss (cognitive-conceptual scheme) was only suggestive, which in Johanna's case would have meant possibly giving up her studies entirely.

The subject's depression was assessed with the Beck Depression Inventory self-assessment form that had been translated into Finnish (Beck et al., 1961 ) that comprised of 21 items. In each item, there are 4–7 alternative statements that have been awarded points from 0 to 3. The items depict attitudes and symptoms related to depression and the severity of the depression from neutral to severe (0 = neutral, 1 = mild, 2 = relatively severe, 3 = severe). The full score of the BDI is 63. The clinical norms of the Inventory are: neutral or not depressed (0–9 points), mildly depressed (10–18), relatively severely depressed (19—29) and severely depressed (30 to 63) (Beck, Steer & Garbin, 1998). The form is a reliable and valid tool for assessing the severity of depression (Beck et al, 1988 ; Beck, Ward, Mendelson, Mock & Erbaugh, 1961). The indicator also gives information on changes in the severity of depression, so it is also a reliable aid when examining the effects of therapy (Beck et al., 1961 ).

The BDI-form was used to gather information in the middle of the course, both midways through it and at the end of it. The subjects were also given a form to fill out approximately two months after the group sessions had ended. In the initial measuring, Johanna's BDI score was 25. According to the BDI-indicator, her depression was relatively severe.

Assimilation analysis is a research methodological trend used for measuring the effects of psychotherapy. According to Stiles et al. ( 1990 , 1991 ), the client's troubling experiences assimilate into already existing knowledge structures in successful psychotherapy. In the course of the therapy, the client aims to give his/her experience new meanings and the experience integrates into a part of the client's schema structures. The assimilation model takes into account both emotional and cognitive change processes. To analyse the stages of assimilation, we can use the APES (Assimilation of Problematic Experiences Scale) developed by Stiles et al. ( 1990 , 1991 ). The stages of assimilation are demonstrated in Table II .

Summary of the stages of assimilation of problematic experiences scale (APES).

Assimilation can be examined as a continuum in which the assimilation of the problematic experience progresses with the progression of therapy. Assimilation progresses in stages and it is notable that the patient's assimilation process can be at any stage when the therapy begins (Stiles et al., 1990 , 1991 ). Assimilation does not progress rigidly and systematically; there can be regressions.

The closer the client is to understanding the problem, the more focal the problematic experience becomes in his/her consciousness (APES 4, Table I ). From this stage onward, the amount of conscious effort aimed at the problematic experience begins to decline. The neutral state of mind in the beginning of the assimilation process reflects a successful denial of the problem. As the client becomes increasingly aware of the problematic experience, the tone of the emotions becomes more negative. As the assimilation progresses, the anxiety will gradually lessen and the mood becomes more positive: the problem is understood and solved. When the problem is under control, emotions regarding it become neutral.

Data collection

The assimilation analysis can be carried out in many different ways (Stiles & Angus, 1999 ; Stiles & Osatuke, 2000 ). However, it is possible to separate four steps that one can follow to ease the process.

I Getting to know the data and listing

In this study, the basic data consisted of videotapes, consisting of approximately 30 h of footage. The analysis was begun by watching all the tapes through carefully (carried out by JK, the other author of this article). He noted the topics the subject addressed in the order they were discussed. The topics noted were attitudes or actions directed at a specific object. The topic could be, for instance, hopelessness in regards to writing the thesis and studying. The main purpose of this work stage is that the researcher acquaints himself with the data as much as possible.

II Recognizing and choosing the themes

The theme that will be examined can be a repeatedly expressed attitude or object (Stiles et al., 1991 ; Stiles & Osatuke, 2000 ). The research problem directs the choice of theme. The researcher can choose a theme that is (a) focal or important in the therapy, regarding which; (b) there has been remarkable progress, regarding which; (c) there has been little or no progress; or (d) some other interesting theme. It is best to describe the chosen theme's contents as clearly as possible, for example, by using certain key words.

In this study, the themes were chosen on the grounds that these topics seemed to emerge as focal and important for the subject. In this subject's case, her relationship with herself as a student was most prominent, because the subject brought this topic up constantly when she spoke up. The course dealt with many factors related to studying difficulties. Mainly because of that, the central themes, such as problematic experiences of the subject, were related to studying and difficulties therein.

III Separating parts related to the theme

At this stage, the parts of the material that deal with a certain theme or problematic experience are collected from the material (Stiles & Angus, 1999 ; Stiles & Osatuke, 2000 ). In practice, at this stage the footage was viewed again. By now, the material had already been quite well outlined since the subject's topics had been listed. At this stage, the subject's addresses were actually transcribed word for word.

IV Description of the assimilation process

At the final stage of the analysis, the assimilation is examined from a theoretical point of view. The examination is based on what happened to the problematic experience during therapy. In this study, the examination was performed by classifying the parts that dealt with the themes according to the theoretic stages of assimilation (APES).

Ethical considerations

Names and identification data were changed so that the person is not recognizable. The students were told that the sessions were videotaped for the purpose of the study and the data would be published in a scientific forum. After that, all information would be destroyed. The information was also given in the paper, and they signed on the dotted line.

We named Johanna's problematic experience as a difficult relationship with herself. In the beginning, this was unclear. Johanna's APES was 1/7: she preferred not to think about her problematic situation and her feelings were anxiety and anger. The connection between Johanna's feelings and the problematic experience was unclear. In the fourth session, the problematic experience was identified for the first time. In the seventh and eighth sessions, her understanding of her problematic experience increased. Her understanding fluctuated back and forth. At the end of the course, her attitude gradually became assimilated into her schemas: she found new perspectives on her academic problems. The connection between intervention and its results can be found by describing the therapy process and reporting the relevant utterances (McLeod, 2001 ). In the next section, we describe the process by showing some of Johanna's comments during different sessions (APES number shows the stage in assimilation model, Figure 1 ).

The results of APES analysis over the course of the 16 group sessions. The Y axis shows the stages in the assimilation model. The X axis shows the number of the sessions.

In the first session, Johanna expressed her hopelessness regarding her thesis. In her speech, there was also an emphasis on her sensitivity to criticism and to other people's advice. The connection between Johanna's feelings and the problematic experience was unclear (APES 1: unwanted thoughts):

Johanna: …I've been studying seven years or started these studies seven years ago. And the thesis I've been doing for a bit over a year [is] going nowhere. It's like that no one can say anything about it. I can't listen to any advice on it and the like. And no one close to me can say anything like now I'll get so down if I can't get it done. And then I really can't get it done.

In the second session, Johanna expressed that she was very critical of herself and of her progress in her studies (APES 1.5: unwanted thoughts and vague awareness):

Johanna: …Now I've totally been lazin' and stuff. Like I left my job last year so that I could work on that thesis. I haven't been working on it. I haven't been able. Then it becomes like kinda …that you can't like …like, you can't allow anything nice to yourself, you know. It's like I should be doin' it now that I got the time. Therapist: Let me clarify, you mean that when you feel you haven't done enough, then you can't like enjoy yourself or just do nothing.

During the third session, the group discussed the fact that it would be good to commend oneself every day for the things one has done. Johanna found it quite hard to give herself credit (APES 1.5: unwanted thoughts and vague awareness).

Therapist: How can you give credit? What could you tell yourself, for example, Johanna? Johanna: I dunno. Therapist: Try it. …Or think about it. Johanna: Well maybe like that you've been doin' stuff all day. That you haven't like ran outta steam in the middle. Therapist: Yeah. So you could say daily that you've done well.

In the fourth session, Johanna disclosed that she felt she lacked the self-discipline required to write the thesis. The problematic experience began to take shape (APES 2: vague awareness/emergence):

Therapist: Johanna, would you like to say something to this? Johanna: I dunno, I got like …that thesis; it's like mainly the self-discipline. …That I'd like have enough discipline to, like, take a hold of it. Cos sure I'd rather be somewhere else doin' somethin' fun.

The difficulty that Johanna experienced in giving herself credit came up again during the fourth session. She expressed the existence of a problematic experience quite directly (APES 3: problem statement/clarification):

Therapist: And Johanna, have you remembered (to give yourself credit)? Johanna: [Shakes her head] No. Therapist: You haven't? Johanna: It's somehow not. …It goes against my nature. I don't know how. …I can't. Therapist: That, that when you try, then you've done so much everyday stuff. Then you do a huge amount. It's like an employer not paying salary. So then … You get through so many, many difficult things.

In the seventh session, Johanna told the group that undone work dampened her spirits and paralyzed her from acting. Her understanding of the problematic experience was improved (APES 4: Understanding/insight):

Johanna: My last week was like, that I was sick on the weekend and early in the week … Therapist: When you got better, what was the biggest obstacle that you didn't touch those papers? Johanna: I dunno. Maybe it was a kinda feeling of incapability that just like took me with it. Therapist: Did you then have this feeling like everything's gone to waste or? Johanna: Yeah. Not when I was sick, then I just didn't have the energy. So that, I just let slide. But um then that … Then after it I'd just lost that whole week. It's like, it's gotta start with Monday or it won't start at all. I just got that feeling. Therapist: It's funny, that it's kinda like a sort of programming. But d'you think that this thought of everything going to waste paralyzed you? Johanna: Yeah, probably.

In the eighth session, Johanna groped for words as she tried to describe her new views on studying and writing her thesis that she had learned from the course. Here, Johanna's newly-found tolerance toward herself and her behaviour was apparent. Writing her thesis no longer seemed completely mandatory; instead, Johanna felt that she could do other things, even if she was not working on her thesis. She worked on her problematic experience further (APES 5: application/working through):

Johanna: …I got a lot of new views from others and stuff to think about. Therapist: Which new views did you get? Johanna: Well … The one about that um … you do little by little and then you can like rest. And like that when you don't give yourself permission to do. That it would be like important just so that you can stay in shape and then work again. Therapist: Wait, did I get this right, that when you something, you'd do it. But then on the other hand you'd give yourself permission to do other stuff and enjoy that too. Was that what you meant? Johanna: Wait a sec …I meant that like, if you're not doing the thesis, it's still okay to do something else.

In the ninth session, Johanna felt that giving herself positive feedback was quite difficult. She was, however, able to give herself some positive feedback, but negative thoughts and criticism took over her mind very easily. This depicted Johanna's severity on herself (APES 4.5: understanding and working through).

When the group had met ten times, Johanna had been able to become more active with her thesis. She still felt, however, that the more she focused on studying, the lower and the more desperate she felt. Criticism and severity could be heard in Johanna's speech (APES 3.5: problem statement and understanding).

In the eleventh session, Johanna said that she needed instruction on her thesis, but she was afraid of going to meet her instructor. Here, Johanna's feelings of hopelessness with her studies and her thesis became apparent. Alternatively, it seemed that she was ashamed that she had not achieved what she thought was enough (APES 4: understanding/insight):

Johanna: I'd really probably need like my own field's point of view at this stage and …I just somehow don't dare to go to the department. …I just don't dare go there. Therapist: What scares you? Johanna: I dunno. It just makes me feel like that, I'm a loser and I'm so totally lousy, and now it's been so long, and more time just keeps passing. It's like this endless circle … or kinda like, it's too late now.

Later in the same session, Johanna said that she felt she got support from the group. She worked on her experiences some more. The emotional tone was positive and optimistic (APES 5: application/working through):

Therapist: What do you hope from us (the group)? Johanna: Well, I hear all kinds of … well I hear stories here, survival stories. [Laughs.] Therapist: [Laughs.] This is a survivors' club. Johanna: Maybe that kinda gives hope, that maybe I'll be brave enough to go there [to the instructor], because now I've got it figured out what my next step is, that I should take to get forward.

In the twelfth session, Johanna reflected upon her determination to work on her thesis (APES 5: application/working through):

Therapist: …Now that you've been more active, what's helped you? Johanna: Well just that like you've decided once and for all that now you gotta do it. That I … well first of all, I went to see the professor right then, that week [Therapist: Yeah.] when we talked here. Therapist: Good, great. Yeah. And you didn't get eaten there. Johanna: Right. And now I have this like …or that kinda feeling that it's now or never. That otherwise it will just stay here, and I can't leave it now. It'd be even harder to start. Therapist: So does that mean that you've made yourself an action plan? Johanna: Well, a bit like that, yeah. That I don't have to have like a schedule [Therapist: On how you'll go on.] but just so that …. Johanna: Every day I should get something done. –

In the thirteenth session, Johanna brought up the fact that she could get studying done little by little. She had learned to have mercy on herself (APES 5.5: application/working through and problem solution):

Therapist: How about your studies this week? Johanna: Well. I studied stuff on Tuesday and Wednesday. Therapist: Great. Johanna: But then I've had these gap days. Therapist: Have you given yourself credit? Johanna: Well, I have tried or at least be happy even if I don't do a lot. Cos I get something …like reading stuff. Therapist: This sounds great. So what's your recipe now? Johanna: Like one day at a time. If it feels bad, then you can like …give it a rest, you know, and do something else.

In the fourteenth session, Johanna listed her short-term priorities. Her short-term aims reached the time-line of approximately six months. In addition to working on her thesis, Johanna mentioned recovering even further from her depression as a goal. In addition, the fact that Johanna was happier with herself was clear; this had increased during the group sessions (APES 5.5: application/working through and problem solution):

Therapist: How about Johanna? Johanna: Well I pretty much have the same things [as the others] that I've put down. I wanna have the thesis like up and running, so that it kinda takes care of itself or that like …I could see the end of it already. And that I'd move past the depression, that I'd be like rid of it already. I dunno. That I'd be happy with myself. Therapist: You have that too, to be happy with yourself. Johanna: Yeah. Or like, yeah. Therapist: Yeah. Do you feel that it's increased during this group, that being happier with yourself? Johanna: Yeah, probably.

The fifteenth and the sixteenth meetings of the course were held together as a single four-hour session. During this session, it came up that Johanna was less critical of herself. She said she could write her thesis gradually (APES 6: problem solution):

Therapist: What have you done lately when you said ‘I've done’? Johanna: And that um …I've been reading. Reading some of the stuff I got, some materials. And then I've just written straight to the computer. And that text doesn't matter at this stage that it's just like some text. Therapist: Yeah. Johanna: That I can like mould it later into what I want. That's just it, cos it's that starting up that's hard for me, that writing is kinda hard. I could really think about one sentence for half an hour. Then it's just gonna go nowhere. So I'll just write then, even if it's not perfect language yet. Therapist: It's probably good that you do it like that. Johanna: It's like I get something done. I get that kinda … Therapist: So is this a new method that you've developed, that you just write ahead? Johanna: Well, yeah. I think it kinda is. The whole time it just kinda gets more fluent and like um …the text [Therapist: Yeah.] and the like, the way it comes out. [Therapist: Yeah.] And It's probably the reading too that does it, the more familiar the thing is the easier it gets, of course and the easier it maybe is to write.

Johanna felt that her beliefs regarding her own actions had changed. She had found new perspective and relief for her problems from the group (APES 6: problem solution):

Therapist: But Johanna, is it kinda like, you've seen that these kinda things don't have to knock you down, that you've then changed your beliefs on your own actions? Johanna: Yeah. Or like. … That this [problems with the thesis and depression] isn't such a big monster anymore. Then when here you've had to and it's been okay to talk about it, then it's not. … It's like easier to take that thing. It's not so big anymore. That you can talk about it. You gotta bring it up once a week anyway, it gets smaller. I don't really know.

As the course went on Johanna was increasingly vocal about having mercy on herself and being happy with herself. She spoke about having received support from the group and was learning to commend herself. Little by little, she became less critical toward herself. She had more room in her inner world. Her tolerance toward herself had a positive impact on Johanna's ability as an actor. She began to work on her studies gradually and it also became easier for her to do other things besides studying.

Finding the ability to be merciful led, in Johanna's case, to increased determination and assertiveness regarding her studies. She wanted to finish her thesis and felt that the thesis was no longer “some monster.” In other words, Johanna got more motivation to continue her studies and to finish them. These new views formed another self-state in Johanna. Johanna's symptoms of depression eased and her ability to act improved.

In the initial measuring, Johanna's BDI score was 25. According to the BDI-indicator, her depression was relatively severe. Four months later, the score was 23 and two months after that, it was 19. At this point the course was finished. A follow-up measuring three months later showed the score was 12, which meant that Johanna was, according to the BDI-indicator, only mildly depressed. Johanna's BDI-score kept decreasing throughout the course, and also after it. She felt that her depression eased during the group meetings.

Johanna's problematic experience (APES) progressed as the meetings continued from level 1 (unpleasant thoughts) to level 6 (solving the problem) ( Figure 1 ). In the beginning, Johanna's problematic experience manifested itself as severe and excessive criticism toward herself and her study performance. The assimilation of Johanna's problematic experience was facilitated by learning different methods of depression control in the group.

Discussion and conclusions

During the course, Johanna directed her energy toward surviving depression, finishing the course and carrying out the assignments given in the group. If working helped in recovering from depression, we can assume that after the course, Johanna had even more resources to direct her actions at, for instance, her studies and particularly on writing her thesis.

Johanna expressed plenty of severe and excessive criticism aimed at herself during the course. According to Guidano's (1991) theory, “I” represents the experiencing and reacting side of the human mind and “self” represents the evaluating and observing side. In Johanna's case, “me” was very rigid and severe, even merciless. This side of her mind attributed that the lack of progress in her studies and other negative experiences were her own fault. Depressive, negative attribution style is a central method of self-regulation in depression (Beck, 1976 ; Beck, Rush, Shaw & Emery, 1979 ). In Johanna's case, the rigid and severe “me” produced negative, permanent inner attributes. These assessments were the source of the severity and harsh critique she directed at herself. By examining this according to Guidano's (1991) theory, Johanna became more lenient in the assessments “me” made of the actions of “I”. This was seen in Johanna's case as the depressive, negative attributions becoming less prevalent.

Of the schemata belonging to the loss or deprivation mode, the behavioural scheme, in particular, changed in Johanna's case during the course. Passiveness and withdrawal made way for her new determination and assertiveness toward her studies. The feelings of hopelessness seemed to go away, so the motivational scheme can also be said to have changed for the better. Alternatively, Johanna reported that her role as an actor regarding her studies remained rather passive throughout the course. The contents of the affective and physiological schemata also underwent a positive change. Johanna's melancholia eased and she gained strength to continue her studies.

The assimilation of Johanna's problematic experience was facilitated by her learning different methods of depression control in the group. Treatment aimed at depressed students would do well to teach structuring one's studies and methods of mood-control and life-control skills (Brackney & Karabenick, 1995 ; Lam et al., 2003 ). The approach of this course was specifically psycho-educative. Johanna felt that she had also received peer support from the group: she had heard how the other group members had managed to get their studies started.

One of the focal questions in this study was whether or not finishing the course helped in combating depression and studying difficulties. The results indicate that the subject's depressive symptoms eased and her role as a student became more active. In the group, mood-improving techniques were also taught. The depression-control skills taught were important.

When examining the change process, we can distinguish two kinds of change processes: superficial and deep changes (Guidano, 1991 ). The group members' troubling feelings were not discussed at great length in the group. This can be a sign that the achieved changes happened mainly on the superficial level of the psyche. Deep level change cannot take place without active work on the emotions related to the problematic experience (Greenberg, 2002 ; Greenberg & Paivio, 1997 ; Guidano, 1991 ). Thus, the achieved changes are not necessarily very permanent. In the follow-up meeting, the subject's BDI-score had continued to decline, although she was still, according to the BDI, mildly depressed.

In Johanna's case, the single most important factor that promoted change was sharing and examining the contents of the problematic experience with the therapist and the group. The group members took turns in examining their problematic experiences in the group and in this way, they supported each other. All members felt that peer support was important. The group leader taught mood-control skills that each group member exercised independently outside the group. Johanna reported that she had found learning how to schedule her time particularly useful.

Johanna's problematic experience became less restrictive through the course. This led to more lenience toward herself and more determination and assertiveness toward her studies.

The downside of working in a group was the fact that the attention of the therapist and of the whole group was divided among six people. At times, it seemed that none of the group members had the opportunity to express and work on their issues adequately in the session time frame. The therapist took an encouraging and supportive approach: he actively strove to pay attention to each group member and to include them all in the discussions. On several occasions, however, it seemed that the two-hour session was far too short a time for this group.

Some of the group members were receiving treatment elsewhere while they attended the course. Consequently, in this study we could not control, for instance, the effects of medication on the lessening of a person's depressive symptoms. In addition, some group members had a discussion contact with a mental health professional outside the group.

In assimilation analysis, determining the subject's APES stages was sometimes rather difficult. At this point, the summary of the stages of assimilation ( Table II ) was quite helpful. It was often so that a seemingly essential utterance by the subject was found, but determining the APES stage was difficult nonetheless. Eventually, seemingly correct stages were found for all excerpts. Finding the correct APES stages was aided by repeatedly reading the subject's utterance and assessing the excerpt according to the amount of cognitive processing and in light of the emotional content. However, the final text probably contains utterances that could have been rated otherwise. Thinking critically, the data achieved by assimilation analysis could be said to be, in all its detail, merely approximate and dependent on the researcher's interests. Alternatively, we should, of course, bear in mind that the APES stage given to a single utterance is not very significant in the scale of the entire change process.

In Johanna's case, the conceptualized problematic experience could have been, for instance, hopelessness regarding studying, and the effect of negative thoughts on studying or getting support from other people. In this case, the research problem directed the choice of themes. Furthermore, the problematic experiences had to be such that they could be conceptualized into suitable units.

The fact that the analysed data is mainly linguistic can be seen as a weakness of the assimilation analysis. This deficiency is a drawback with most qualitative research methods. The verbal descriptions of the subjects do not always accurately convey the relevant contents of the meanings or the emotions related to them. However, if the analysis is to be successful, it has to recognize the subtle nuances and feelings from the material. That is why we used videotapes: the chance to check the process in video deepens the researchers' understanding.

The very concept of a problematic experience can easily be challenged. In this study, the subject's problematic experiences were the themes that were discussed often and at length. However, other criteria could have been used to choose the problematic experience. The themes conceptualized as problematic experiences could also have been, for example, themes for which there was great progress or for which there was little or no progress at all. Alternatively, another interesting theme could have been chosen.

From an economical point of view, it must be mentioned that with a course such as this, a large number of people can be treated relatively quickly. Nowadays, there is pressure to treat depression as cost-effectively as possible (Bright at al., 1999). Group treatment is substantially less costly than individual treatment. The studied group had 16 gatherings, and sessions were two hours each. The group had six members from beginning to end. If they had each had an individual appointment 16 times, there would have been 96 meetings altogether.

One viewpoint is that coping with depression can be taught. One outlook could be introducing depression school as a part of general, basic health care, for instance at schools. The aim could be to teach mood-control skills to persons predisposed to depression, before they become ill. It would be reasonable for the sake of these people themselves, because it would save them from a great deal of human suffering. In addition, this practice would be sensible for society as well, because economically, it would be much less costly than long-term treatments and sick leaves. However, more research is needed to determine this.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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