CONTROVERSAL QUESTION: Do you take positive emotions into account while treating depressive patients?

Do you take positive emotions into account while treating depressive patients?

1. L. A. Alekseeva, Russia
2. M. Bauer, Germany
3. K. Bazaid, Saudi Arabia
4. R. Evsegneev, Belarus
5. V. Gentil, Brazil
6. D. Marazziti, Italy
7. J. Marques-Teixeira, Portugal
8. Y. M. Mok, Singapore
9. M. Nasreldin, Egypt
10. E. T. Oral, Turkey
11. M. A. Rangel, Mexico
12. M. Rufer, Switzerland
13. A. B. Singh, Australia
14. M. H. Tyal, Morocco
15. A. M. Zain, Malaysia

1. A. S. Avedisova, Russia

Alla Sergeevna AVEDISOVA, MD
Department of Psychic and
Behavioral Disorder Therapy
Serbsky National Research Centre
for Social and Forensic Psychiatry
23 Kropotkinsky per.
119992 – Moscow

Emotional disorders are paid less attention in psychiatry than affective disorders. It is not a coincidence, as discrete emotional reactions to specific events are rare causes for medical consultation, and usually reflect an underlying mood alteration such as depression. For depressive patients, the issue is not so much the loss of their usual and almost imperceptibly “normal” mood, but rather an emotional reaction that develops in acute form (eg, anguish, sadness, anger), instantly uniting all body functions. The essence of the psychic mechanisms that develop and intensify these emotions lies not in their potentiation by depressive affect, but in their compensatory role: the emotions compensate, at least in part, for lowered mood, and are thus necessary to maintain life activity. Consideration of emotional reactions plays an important role when choosing a treatment strategy and individualizing therapy, and also in ensuring treatment compliance and predicting antidepressant effectiveness. The decisive role of emotions in governing human actions is reflected in the motivation theory of emotional origin, which postulates that emotions and motivations are essentially similar. The question of which emotions to consider in ensuring compliance and motivation of a patient is not rhetorical. In positive psychotherapy, positive emotions are developed, whereas psychoanalysis focuses on eliminating negative emotions.

The issue is tied to numerous psychological theories on the origin and role of emotions in human life. A black-and-white division into positive and negative emotional states is an oversimplification of complex events: negative emotions may give rise to a positive emotion (eg, envy of a person changes into joy after that person’s defeat) and emotions may be positive and negative in different moments (eg, melancholy caused by romantic love). It is not emotions themselves, rather their effects on human activity and the impression they make on others that is positive or negative. Therefore, negative emotions are as necessary and adaptive as positive ones. Doctors should consider the entire emotional spectrum in depressive patients to attain compliance. The more a patient shows both positive and negative emotions (especially during first treatment steps), the more successful is the process of motivation. To a great extent, this depends on the doctor’s competence in helping patients become aware of their own emotions and to value them(reflective training); not trying to replace the negative emotional background with an artificial positive one. When the quality and amount of information given is inadequate (including about planned treatment), emotions also fill in for lacking information, compensating for unavailable knowledge (cognitive component of emotions). Thus, the process of informing a patient is an additional part of emotion management in depression.

Emotions are closely connected to neurophysiological systems, and there is a relative interaction with cognition and dependence on needs. Notions of negative and positive emotions are also relative. This ambivalence is especially obvious for the emotion of expectation (anticipation): it combines the wish for something to happen (positive component) with concern that this might not happen (negative component). Expectation performs a prognostic function and manifests as stress augmented by uncertainty. This emotion (expectation, feeling of future treatment success or failure) is considered a trigger to the placebo effect. We developed the Questionnaire of Therapy Expectations (14 items) to obtain information about depressive patients’ expectations of pharmacological treatment. Several topics were surveyed: whether patients consider their condition to be (un)treatable, previous experiences with depression treatment (positive or negative), expected time frame for onset of therapeutic effect, and whether treatment side effects are expected and, if so, how severe. After a week of placebo therapy, most responders were found to have positive expectations (39.7%) and only 3.6% had been unsure. Placebo nonresponders included all patients with negative expectations (34.9%) and 21.6% of unsure patients. As the placebo effect is an important part of antidepressant activity, the emotion of expectation may predict whether or not pharmacological treatment will be effective. _

2. M. Bauer, Germany

Michael BAUER, MD, PhD
Professor of Psychiatry
Department of Psychiatry and Psychotherapy
University Hospital Carl Gustav Carus
Technische Universität Dresden
Fetscherstr. 74
D-01307 Dresden

Emotion is the generic term for subjective, conscious experience characterized primarily by psychophysiological expressions, biological reactions, and mental states. The most distinct classification of emotions to date is probably Parrot’s 2001 theory.1 Parrot identified over 100 emotions and conceptualized them in a tree-structured list comprising primary (fear, anger, sadness, surprise, joy, and love), secondary, and tertiary emotions. Emotions can also be grouped on a positive or negative basis; eg, joy versus sadness, trust versus distrust, or surprise versus anticipation.

Many different components of emotion form integral parts of the clinical syndrome of depression, but a mood disturbance is considered the core symptomin depressive disorders. However, depressed mood and negative emotions like sadness do not necessarily constitute a psychiatric disorder. They are a normal reaction to certain life events, symptoms of some medical conditions, and a side effect of some medical treatments.2

Although the subjective feelings described and expressed by most melancholic people do bear some resemblance to the mood changes of everyday life, they clearly go beyond the common experience.2 A patient suffering from depression experiences painful negative emotions, and has an inability to respond to or generate pleasurable stimuli. The painful dimension of depressive experience during illness is usually related to anxiety, guilt, anguish, and restlessness—an agitated state of emotional arousal that we consider to comprise negative emotions. A general blunting of emotions is considered an important feature of clinical depression.3 Positive emotions such as enjoyment, happiness, passion, enthusiasm, and excitement are typically reduced in people suffering from depression. Most importantly, negative emotions like sadness, anger, aggression, and anxiety are usually increased in depressive states. Interestingly, the term emotion does not appear in the symptom description of major depression in both the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Statistical Classification of Diseases, Tenth Revision (ICD-10) classification systems of mental illness.

Some patients suffering depression report subjective negative emotional symptoms that seem to arise as an adverse effect of antidepressants and lithium salts. This phenomenon was described in the early 1990s as emotional blunting; for example, in patients treated with selective serotonin reuptake inhibitors (SSRIs). Dose-related symptoms that disappeared shortly after withdrawal of fluvoxamine or fluoxetine were apathy, indifference, loss of initiative, and disinhibition.4 Overall, relatively little research has been published to clarify whether symptoms of emotional blunting are indeed related to treatment with SSRIs or represent residual symptoms of depression.3 Recently, a rating instrument, the Oxford Questionnaire on the Emotional Side-Effects of Antidepressants has been developed and validated.5 This scale offers the opportunity to measure emotional blunting during treatment with antidepressants in the clinical setting.

Depressed people may experience a variety of different positive and negative emotions, the latter including sadness, anxiety, emptiness, hopelessness, worry, helplessness, worthlessness, guilt, irritability, hurt, or restlessness. They may lose interest in activities that once were pleasurable, experience loss of appetite or overeating, have problems concentrating and in remembering details or making decisions, and may contemplate or attempt suicide. These symptoms can come and go within hours, days, or weeks, and may give the patient the feeling of riding a frightening rollercoaster of emotions.

When positive emotions slowly return in a patient suffering from melancholic depression, it is often a first sign of response to treatment. Therefore, it is important to monitor not only the reduction in negative emotions, but also the return of positive emotions during treatment. It is also of clinical relevance to identify symptoms of emotional blunting that may occur during a course of treatment with psychotropic medications. This latter area of research has been widely neglected in the past. _

1. Parrott W. Emotions in Social Psychology. Philadelphia, PA: Psychology Press; 2001.
2. Whybrow PC, Akiskal HS, McKinney WT Jr. Mood Disorders: Toward a New Psychobiology. Plenum Press; 1984.
3. Price J, Cole V, Goodwin GM. Emotional side-effects of selective serotonin reuptake inhibitors: qualitative study. Br J Psychiatry. 2009;195(3):211-217.
4. Hoehn-Saric R, Lipsey JR, McLeod DR. Apathy and indifference in patients on fluvoxamine and fluoxetine. J Clin Psychopharmacol. 1990;10(5):343-345.
5. Price J, Cole V, Doll H, Goodwin GM. The Oxford Questionnaire on the Emotional Side-effects of Antidepressants (OQuESA): development, validity, reliability and sensitivity to change. J Affect Disord. 2012;140(1):66-74.

3. K. Bazaid, Saudi Arabia

Psychiatry Department
College of Medicine
King Sand University
PO Box 2611971
Riyadh 113112

Mood is an emotional state, although the terms mood and emotion may be used interchangeably. Moods differ from emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event. Moods generally have either a positive or negative valence.

Clinicians usually manage to alleviate depressive symptoms, and most of the time they will be satisfied that they have regained the patient’s baseline (euthymic) mood. Patients will be pleased to regain their energy and restart functioning, but they will not necessarily feel or think positively about themselves, particularly if only treated with antidepressants. Studies indicate that the majority are apprehensive and worried that they may go back to their horrible gloomy mood, and usually fail to resist the recurrent negative themes during their recovery course.

Even though research on emotions has flourished in recent years, investigations that expressly target positive emotions remain few and far between. Any review of the psychological literature on emotions will show that psychologists have typically favored negative emotions in theory building and hypothesis testing. In doing so, psychologists have inadvertently marginalized the emotions such as joy, interest, contentment, and love that share a pleasant subjective feeling.1

In contrast with biological treatment of depression, most if not all psychotherapy treatment models aim to alter the content of underlying cognitive structures that influence affective state and behavioral patterns. For example, in the case of apathy, resulting from a person’s expectation of failure in all areas, the patient is actively taught to experience reactive emotions through correction of their cognitive state.

In my clinical practice, I work with patients presenting with depression to try and understand its correlation with their adaptive abilities during stressful and difficult times, and I may use their intellectual belief, eg, belief in God’s will, which is culturally accepted, to relieve their guilt and decrease sense of self blame. In doing so, most of them will gradually experience joy, which will eventually help to improve their cognitive state. Additionally, I work with them on improving their social skills as an alternative means of reducing subsequent negative impacts resulting from and/or causing their depression, whether related to study, work, or even relationships.

Studies have reported impaired executive function in patients with major depressive disorder, with positive correlations with depression severity and illness duration. There are also studies suggesting that these patients have the same level of impairment, or less impairment, as depressed bipolar patients.2

Happy people are more likely to succeed in achieving culturally valued goals (eg, work, love, and health) than their less happy peers. However, the large number of available correlational studies in this area includes research examining behavior and cognition in parallel with successful life outcomes— that is, the characteristics, resources, and skills that help people to succeed (attributes such as self-efficacy, creativity, sociability, altruism, immunity, and coping).3

Despite the increased focus on self-esteem over the past three decades, depression in children has continued to grow, now affecting a quarter of all children today. Although the midterm outcome is often favorable, the prognosis of depression in the young is often poor, with 75% experiencing relapse at 5 years,4 thus considerably increasing the risk of depression in adulthood.5 To combat this trend, Dr Seligman began the Penn Depression Prevention Project, the first long-term study aimed at 8- to 12-year-olds. His findings were revolutionary, proving that children can be protected against depression by being taught how to challenge their pessimistic thoughts (Seligman’s learned optimism). _

1. Fredrickson BL. What good are positive emotions? Rev Gen Psychol. 1998;2(3): 300-319.
2. Phillips ML, Drevets WC, Rauch SL, Lane R. Neurobiology of emotion perception II: implications for major psychiatric disorders. Biol Psychiatry. 2003;54: 515-528.
3. Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: does happiness lead to success. Psychol Bull. 2005;131(6):803-855.
4. Kovacs M, Feinberg TL, Crouse-Novak MA, Paulauskas SL, Finkelstein R. Depressive disorders in childhood. I. A longitudinal prospective study of characteristics and recovery. Arch Gen Psychiatry. 1984;41:229-237.
5. Harrington R, Fudge H, Rutter M, Pickles A, Hill J. Adult outcomes of childhood and adolescent depression: II. Links with antisocial disorders. J Am Acad Child Adolesc Psychiatry. 1991;30:434-439.

4. R. Evsegneev, Belarus

Professor and Head
Department of Psychiatry and Narcology
Byelorussian Medical Academy of
Postgraduate Education
Republican Scientific and Practical Centre
of Mental Health
Dolginovskyi tract, 152
220056, Minsk, BELARUS

At first glance, the question seems to be nontraditional and unusual, especially for psychiatrists with a strict psychopathological, Kraepelinian, and “antipsychodynamic” orientation, which is common in the post-Soviet countries. This approach is considered to help avoid missing the transition to hypomania, and differentiates unipolar depression from bipolar II and mixed states.

However, the meaning of the question, and hence the role of positive emotions in the treatment process, appears much more profound when one considers the dramatic impact that psychodynamic and interpersonal factors have on responsiveness to pharmacological treatment for depression—ie, transference and countertransference, defense, conscious and unconscious benefits derived from the state of depression, etc.1 An important part of the treatment process also involves knowledge of a patient’s previous life experience—ie, their behavior and interactions when in a good mood state with positive emotions.

Practical experience suggests that psychological and psychodynamic factors such as the image of psychiatrists, the style of doctor-patient communication, therapeutic alliance and positive transference, patient expectations and readiness to change, and secondary gain could be even more potent in determining treatment outcome than the biological effects of antidepressants.2 It seems to be very important during the treatment process to demonstrate and remind patients of their life—including emotions, attitudes, activities, and interactions— before and outside of the period of depression. In other words, not to tell them what is bad when in low spirits, but why it is good to be cheerful and positive and what secondary gains could be reached in different areas of their life from a good mood state with positive emotions. In doing so, it is necessary to emphasize that depression is not “an eternal punishment,” but a time-limited state of illness that, without fail, will eventually give way to a state of health and good mood. This gives an opportunity to make a patient “ready to change,” and in many cases, his motivation to be healthy and cheerful is the most powerful determinant of treatment effectiveness—sometimes more powerful than the type of antidepressant and its dosing, etc. When communicating with patients, it is vital to convey that drug treatment is not a mechanical process of taking pills, but the route away from sadness and suffering to a healthy emotional state and a good, valuable life.

One of the most potent ingredients in antidepressant treatment is the positive transference to the doctor, as well as his or her capacity to stimulate the patient’s positive emotions and expectations. At this point, it is of value to emphasize the importance of proper communication skills and a nondepressive manner; to be able to emit confidence, calmness, endurance, and professional competence. The doctor’s ability to be positive, emotionally stable, cheerful, and tolerant promotes positive transference and hence a therapeutic alliance,2 adherence, and higher placebo response,3,4 with a positive therapeutic outcome as a result. By contrast, pessimism on the part of the doctor and a lack of the aforementioned qualities is associated with negative transference and hence non-adherence, distorted communication, and a paradoxical situation in which medications serve to be counter therapeutic or the aims of the patient become defensive. _

1. Mintz D. Psychodynamic psychopharmacology. Psychiatric Times. 2011;28:1-6.
2. Krupnick JL, Sotsky SM, Simmens S, et al. The role of therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol. 1996;64:532-539.
3. Posternak MA, Zimmerman M. Therapeutic effect of follow-up assessments on antidepressant and placebo response rates in antidepressant efficacy trial: metaanalysis. Br J Psychiatry. 2007;190:287-292.
4. Walsh BT, Seidman SN, Sysko R, Gould M. Placebo response in studies of major depression: variable, substantial, and growing. JAMA. 2002;287:1840-1847.

5. V. Gentil, Brazil

Valentim GENTIL, MD, PhD
Professor of Psychiatry
University of Sao Paulo Medical School
Rua Oscar Freire, 587/11
01426-001 – Sao Paulo

When prescribing antidepressants, one should closely monitor changes in background emotional state in addition to core therapeutic response. Negative emotions naturally command the patient’s attention, but subtle (“extratherapeutic”) positive changes in emotional response to daily events also occur and may deserve recognition, as they inform about the biology of emotional regulation. Besides these often-neglected aspects of antidepressant action, I invite your attention to a particularly distressing emotion formerly known in English psychiatry as “precordial anguish,” and as “angoisse” in French and “angustia” in various Latin languages, a symptom that has all but disappeared from contemporary psychopathology.

Subtle positive changes in the emotional state of some patients in response to treatment were described early in the literature, chiefly with monoamine oxidase inhibitors, but they only received special attention in the 1990s after the introduction of single small doses of selective serotonin reuptake inhibitors. Before that, they could hardly be noted due to sedative or anticholinergic effects, or “blunting” of emotions, induced by various medications.

To determine whether such positive effects are extratherapeutic, my colleagues and I conducted a series of experiments in volunteers without personal or family history of psychiatric disorders.1,2 For the active drug we chose clomipramine, since it induced such changes with small doses in our patients with panic/agoraphobia. In double-blind experiments with propantheline as active placebo, we measured variables of personality, mood, cognition, performance, sleep, and neuroimaging. We identified four domains of subjective change: interpersonal tolerance (decreased irritability and tension in social interactions), efficiency (improved decision-making, ability to prioritize demands, and self-confidence), well-being (feeling better, brighter mood), and feeling substantially changed from usual self. About 35% of participants met the response criteria for such changes. Selecting the responders, we carried out a final crossover trial of three weeks on active drug or placebo. All participants maintained (or reacquired) the response criteria on clomipramine, and lost it on placebo. We concluded that low doses of clomipramine may induce positive changes in emotional response in the absence of psychopathology in some, but not all, individuals. We are now submitting the neuroimaging findings of this trial for publication, which show significant differences between responders and nonresponders (Cerqueira et al, in preparation).

I also pay attention to negative emotional changes in my patients, and I try alternative medications to avoid them.

Turning to the concept of “anguish,”3 the feeling of precordial oppression was described in psychiatric texts in most Latin languages, as well as in English (“precordial anguish”) and German (“Oppressionsgefühl”) texts. Specific words for this ancient emotion are available in unrelated languages, such as Chinese, Hungarian, and Arabic, suggesting a consistent experience across time and cultures. Its distinction from anxiety was lost by modern psychopathology in the 1960s due to problems of translation for “angst,” and because there was no compelling reason to discriminate it from anxiety before modern psychiatric treatment.

Anguish combines the ideas of present pain and agony of mind, and is not universally experienced. It occurs in about one-third of my patients with depressive disorders, typically in melancholic or bipolar depressive states with early morning awakening, but also in the evening in those with inverted diurnal variation, as well as patients with schizoaffective disorders. They clearly distinguish precordial anguish from anxiety, but it may be confused with precordial pain during a panic attack. Anguish is also described, in low intensity, by normal adults and children. Its residual presence at an improving stage means that dysfunction is still present. The pathophysiology of a symptom localized in the chest may primarily involve somesthesic systems related to visceral organs. A drug capable of promoting remission of depressive syndromes must suppress this symptom. The mechanisms, however, require scientific investigation. _

1. Gorenstein C, Gentil V, Melo M, Lotufo-Neto F, Lauriano V. Mood improvement in ’normal’ volunteers. J Psychopharmacol. 1998;12:246-251.
2. Gentil V, Zilberman ML, Lobo D, Henna E, Moreno RA, Gorenstein C. Clomipramine- induced mood and perceived performance changes in selected healthy individuals. J Clin Psychopharmacol. 2007;27:314-315.
3. Gentil V, Gentil ML. Why anguish? J Psychopharmacol. 2011;25:146-147.

6. D. Marazziti, Italy

Professor of Psychiatry
Dipartimento di Medicina Clinica
e Specimentale
University of Pisa
via Roma, 67 – 56100 Pisa

Emotions can be defined as multicomponent responses that develop in a relatively short space of time in response to internal or external stimuli that include subjective experiences, cognitive processes, and psychophysiological changes. Experiencing positive and negative emotions is unavoidable, and at times useful, and both have been selected along the human evolutionary path for their adaptive and survival value. However, negative emotions, when long lasting, deep, or inappropriate, can trigger anxiety disorder or depression and can impair the immune system. Perhaps this is the reason that although research on emotions has increased continuously in recent decades, the majority of studies has focused on negative emotions rather than positive emotions, such as joy, interest, contentment, and love, which all share a pleasant subjective feeling.1 Experiences of positive emotion are central to human nature and contribute richly to the quality of people’s lives, and they have only recently begun to attract research attention, mainly for their impact on psychiatric disorders, especially depression.

In fact, according to some theorists, depression is a disorder in which the core symptoms are represented by a deficit of positive affect and inability to experience positive emotions. This notion is supported by different functional magnetic resonance imaging studies showing that the brains of depressed patients exhibit an overall decrease in activity in the regions of the brain responsible for generating pleasure/reward/positive emotions. Furthermore, other scientists report that although the initial levels of activity in positive/pleasure-generating brain regions are no different between depressed patients and healthy control subjects, patients do not seem to be able to sustain positive emotions. In terms of treatment strategies for depressed patients, in order to take advantage of these emerging findings, more sophisticated and integrated strategies will be needed that are not limited to prescription of drugs, but also include behavioral and cognitive therapies, as well as triggering of coping styles marked by finding positive meaning. With regards to behavioral interventions, patients should be assisted in clarifying their medium- to long-term goals, and in engaging more in pleasant activities. However, psychological treatment should also focus on helping patients to develop a more distributed happiness. Depressed individuals (and nondepressed individuals, for that matter) should create a life in which they receive pleasure and reward from multiple areas of their existence. This bottom-up (behavior to brain influence) approach is more likely to lead to long-term, enduring, positive emotions.

This approach can be achieved by placing more emphasis on finding positive meaning, which seems to be fundamental to eliciting positive emotions. It is noteworthy that positive emotions may not need to be intense or prolonged in order to produce a beneficial effect. Positive emotions can broaden the individual’s thought-action repertoire, which builds and promotes their personal resources. This psychological process can increase an individual’s receptiveness to further pleasant or significant events, while also increasing the odds of finding positive meaning in those events and experiencing further positive emotions. This can in turn trigger an “upward spiral” that might, over time, improve depressive symptoms.2 Thus, the experience of positive emotions might facilitate coping and alleviate depressed mood.

In conclusion, different lines of recent studies support the notion that depression is best treated by an integrated psychological approach aimed at promoting positive emotions in combination with prescription of drugs, and not use of drugs alone. Future antidepressants should be targeted specifically at restoring or improving a patient’s ability to experience positive emotions. _

1. Fredrickson BL. What good are positive emotions? Rev Gen Psychol. 1998;2(3): 300-319.
2. Garland EL, Fredrickson B, Kring AM, Johnson DP, Meyer PS, Penn DL. Upward spirals of positive emotions counter downward spirals of negativity: insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology. Clin Psychol Rev. 2010; 30(7):849-864.

7. J. Marques-Teixeira, Portugal

Aggregate Professor of University of Porto
Rua Alfredo Keil, 480
4150-048 Porto

I do take into account positive emotions in the treatment of depressive patients, by considering their stimulation through neurofeedback. In fact, in many depressive patients, stimulation of positive emotions can be an effective adjunct to pharmacological treatment. Why? A robust body of research has documented that depression is associated with differential activation of the right and left prefrontal cortex. When there is a biological predisposition to depression, frontal asymmetry can be observed with more left frontal alpha activity, meaning that the left frontal area is less activated. Electroencephalogram (EEG) studies have demonstrated that the left frontal area is associated with more positive affect and memories, and the right hemisphere is more involved in negative emotion. Thus, when the left hemisphere is basically stuck in an idling alpha rhythm, there is more withdrawal behavior, in addition to the deficit in positive affect. This means that depressed patients may be anticipated to be less aware of positive emotions, while at the same time being more in touch with the negative emotions that are associated with the right hemisphere.

In addition, evidence also suggests that positive emotions are important facilitators of adaptive coping and adjustment to acute and chronic stress, mainly by sustaining coping efforts, providing a breather, and restoring depleted resources.

It has been proposed that this frontal asymmetry (alpha asymmetry) may represent a state marker of depression, although such an asymmetry is not necessary or sufficient for the production of a specific type of affective style or psychopathology. Differences in prefrontal asymmetry may be most appropriately viewed as diatheses that bias a person’s affective style, and thus in turn modulate a person’s vulnerability to develop depression. It has also been found that alpha asymmetry can be used to predict the response to antidepressants before the beginning of pharmacological treatment, in such a sense that it could serve as an aid in the choice of treatment.

As we gain insight into the relationship between depression and EEG patterns, and in view of the fact that EEG biofeedback (neurofeedback) has been found to be effective in modifying brain function, producing significant improvements in several clinical symptoms, use of neurofeedback in depression is being proposed as a way of training depressed people to change their frontal alpha asymmetry so that it resembles the asymmetry pattern found in nondepressed individuals. As with any form of biofeedback, neurofeedback is built upon the self-learned practice of conscious generation of more healthy organic patterns. The technique represents a form of operant conditioning through which an individual may learn to modify the electrical activity of his own brain. Some patients claimed after training that they could distinguish between emotions generated by depression and those associated with life situations.

Taking into consideration all of the aforementioned information, when planning a therapeutic strategy for depressive patients, I also consider adjuvant neurofeedback training in addition to pharmacological treatment to facilitate patient learning of how to modify their frontal activity by increasing activation of the left hemisphere and decreasing activation of the right hemisphere.

To sum up, asymmetry training is important for controlling and regulating emotion, and it may facilitate left frontal lobe function in depressive patients. _

8. Y. M. Mok, Singapore

Yee Ming MOK, MBBch,
MMed (psychiatry),
Grad Dip (psychotherapy)
Institute of Mental Health
Woodbridge Hospital
10 Buangkok View

As trainees and young psychiatrists, we are taught about psychopathology. We learn to diagnose psychiatric disorders based on abnormal signs and symptoms related to this psychopathology. Treatment, then, aims to eliminate these signs and symptoms. In depression, as defined by criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (Text Revision; DSMIV- TR), the main therapeutic objective is remission: to improve mood, apathy, guilt, and hopelessness, as well as sleep and appetite—in short, the clinical signs of the disorder. The majority of these symptoms will improve with current treatments. However, a significant number of patients experience only partial remission.1 Although they do not have sufficient symptoms in number or severity to constitute a disorder, they do still have some symptoms and they feel that they do not have the same emotional well-being as before. For many, even though they no longer feel depressed, the anhedonia is still present. The presence of such residual symptoms is associated with a higher relapse rate, socioeconomic impairment, and increased utilization of health care services. Positive emotions such as love, joy, hope, and passion do not return; the joie de vivre remains elusive.

Increasingly, there is evidence that positive and negative emotions play a part in the treatment of and recovery from depression. There is a close relationship between depression and physical illnesses such as myocardial infarction, stroke, and cancer. Patients suffering from a physical illness with concomitant depression have a poorer outcome compared with patients not suffering from depression.2-4 Patients with an existing negative emotion profile (introversion, low sensation seeking, autonomy, dysfunctional attitudes, high displeasure capacity, passivity, and pessimism) are at higher risk of developing depression. Positive emotions have been shown to be protective in the prevention of stress and depression. They build resilience. Numerous studies show that happy individuals are successful across multiple life domains, including marriage, friendship, income, work performance, and health. Furthermore, the evidence suggests that positive affect—the hallmark of well-being—may be the cause of many of the desirable characteristics, resources, and successes correlated with happiness. A twin study looking at positive emotions found that such emotions buffer against the genetic risks of developing depression.5 Indeed, having positive emotions has been associated with a longer lifespan. In a study of Catholic nuns, positive emotional content in early-life autobiographies was strongly associated with longevity six decades later.

In light of such evidence, recognizing and optimizing the presence of such emotions early in the treatment of depression would lead to better outcomes. A recent study suggests that looking beyond the elimination of the abnormal signs and symptoms of depression, the early improvement of positive emotions predicts remission from depression after pharmacotherapy.6 Apart from our established treatments for depression that are aimed at achieving an absence of symptoms, we should keep in mind the use of neurobiological treatments, psychosocial therapies, and the spiritual needs of patients to help patients better cope with stress and optimize positive emotions. Having the return of positive emotions as a treatment goal would lead to a better quality of life and lessen the risk of relapse for individuals suffering from depression. To ignore this would be a disservice to our patients as well as to ourselves. _

1. Kennedy N, Paykel ES. Residual symptoms at remission from depression: impact on long-term outcome. J Affect Disord. 2004;80(2-3):135-144.
2. Spiegel D, Giese-Davis J. Depression and cancer: mechanisms and disease progression. Biol Psychiatry. 2003;54(3):269-282.
3. Frasure-Smith N, Lespérance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival. JAMA. 1993;270(15):1819-1825.
4. Pohjasvaara T, Vataja R, Leppävuori A, Kaste M, Erkinjuntti T. Depression is an independent predictor of poor long-term functional outcome post-stroke. Eur J Neurol. 2001;8(4):315-319.
5. Wichers MC, Myin-Germeys I, Jacobs N, et al. Evidence that moment-to-moment variation in positive emotions buffer genetic risk for depression: a momentary assessment twin study. Acta Psychiatr Scand. 2007;115:451-457.
6. Geschwind N, Nicolson NA, Peeters F, van Os J, Barge-Schaapveld D, Wichers M. Early improvement in positive rather than negative emotions predicts remission from depression after pharmacotherapy. Eur Neuropsychopharmacol. 2011;21 (3):241-247.

9. M. Nasreldin, Egypt

Professor of Psychiatry
Psychiatry and Addiction Prevention Hospital
Faculty of Medicine, Cairo University
Kasr El-Aini Hospitals, Cairo, 11451

Despite the importance of negative emotions as major criteria in the diagnosis of major depression, positive emotions are unfortunately frequently not taken into account when treating depressive patients.

Anhedonia, a negative emotion, is considered a core symptom of major depression that involves deficits in the ability to experience positive emotions such as pleasure, pride, happiness, and amusement.1 Depressed patients thus suffer from decreased hedonic ability, which is defined as the amount of positive affect that it is possible for an individual to experience.2 Moreover, anhedonia may not entirely be due to a tonic decrease in the ability to experience pleasure, but rather an inability to preserve positive impact and honor responsiveness over time.3

The value of positive emotions lies in their capacity to enable individuals to build durable personal resources (ie, intellectual, physical, psychological, and social). In addition, positive emotions affect people’s thinking style, social interactions, and physiological responses.4 Positive emotions also broaden the breadth of people’s thinking, attention, and actions moment to moment, while negative emotions narrow it. Thus positive emotions are considered as efficient antidotes to the lingering after-effects of negative emotions.5 However, the ultimate goal in managing depressed patients is to understand how positive emotions might accumulate and compound each other to transform the lives of patients for the better. Hence, there can be several reasons for taking positive emotions into account when treating depressive patients.

First, the proper deconstruction of the depressive episode into all its component positive and negative emotions through the use of self-reports or assessment scales is crucial in detecting a patient’s positive resources, recognizing their character strengths, and helping the patient respond actively and constructively to positive events reported by others.

A second reason is to discuss optimism and positivity using an explanatory style: optimism is to see bad events as transient, changeable. The retrieval of positive and negative memories in relation to current events and their role in the subsequent development of positive and negative emotions is also noteworthy.6

A third reason for taking positive emotions into account is the conceptualization of depression as involving low self-esteem, whereby self-relevant stimuli trigger negative self-appraisals that may dampen the individual’s ability to experience positive self-relevant emotions such as pride, possibly due to a dysfunctional emotion system. Indeed, the need to delineate the relationship between negative self-appraisals and self-relevant positive emotions is crucial when treating depressed patients. Furthermore, it is important to bear in mind that positive self-relevant emotions are multifaceted and include positive emotions associated with personal achievement as well as those based on group membership.6

In conclusion, in psychiatric clinical practice, therapists should consider taking into account negative and positive emotions simultaneously during the management of depressed patients. With regard to positive emotions, therapeutic approaches should not only encourage patients to participate in potentially enjoyable situations, but to practice allowing their pleasant emotions to surface instead of suppressing them. _

1. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, Fourth edition: DSM-IV-TR. Washington DC: American Psychiatric Association, 2000.
2. Myerson A. Anhedonia. Am J Psychiatry. 1922;2:87-103.
3. Tomarken AJ, Keener AD. Frontal brain asymmetry and depression: a self-regulatory perspective. Cogn Emot. 1998;12:34.
4. Fredrickson BL. The value of positive emotions. American Scientist. 2003;91: 330-335.
5. Fredrickson BL, Branigan C. Positive emotions broaden the scope of attention and thought-action repertoires. Cogn Emot. 2005;19:313-332.
6. Rottenberg J, Gross JJ, Gotlib IH. Emotion context insensitivity in major depressive disorder. J Abnorm Psychol. 2005;114:627-639.

10. E. T. Oral, Turkey

E. Timuçin ORAL, MD
Professor of Psychiatry
Istanbul Commerce University
Department of Psychology
Istanbul, TURKEY

The simple answer to this question is “yes, of course.” However, there are other questions involving “why, when, and how” that can explain the rationale behind this simple answer.

Why: it is interesting that even the scientific literature on emotions includes far more publications on negative emotions like fear, anger, and sadness than on positive emotions like joy, interest, and contentment. In 1998, Fredrickson proposed that positive emotions broaden a person’s momentary thought action repertoire.1 Thus, according to this view, positive emotions and related positive states are not only linked to broadened scopes of attention, cognition, and action, but also to enhanced physical, intellectual, and social resources. As emotional intensity has been found to be one of the strongest predictors of outcome in depression, positive emotions may play an important role regarding the values and objectives of patients. Depressive patients frequently want to decrease their experience of negative emotions and increase their experience of positive ones.2

When: it has been hypothesized that a patient’s response to their depressive symptoms plays a role in either amplifying and perpetuating or alleviating their depression. In 1995, Morrow and Nolen-Hoeksema put forward the idea that emotion- focused coping would be expected to perpetuate depression symptoms, whereas task-focused coping or social distraction might be expected to help alleviate depression.3 In a study evaluating the impact of a range of psychosocial factors on the outcome of major depression, it was found that interpersonal events and responses to depression (ie, coping) play an important role.4 This means that positive emotions should be taken into account at every stage in the management of depression, from diagnosis to treatment.

How: antidepressants do not act as direct mood enhancers, but rather change the relative balance of positive to negative emotional processing, providing a platform for subsequent cognitive and psychological reconsolidation.5 While similar in efficacy to other antidepressants, the selective serotonin reuptake inhibitors (SSRIs) are generally considered to be better tolerated, and thus have a high market share as a consequence. However, an unforeseen and common side effect of these drugs can be emotional blunting, which is really underestimated. Although blunting of emotion is not described as a potential side effect in package inserts, many clinicians have noted that patients being treated with SSRIs frequently complain of this.

In a study conducted in 2002 by Opbroek and colleagues, compared with controls, depressed patients reported significantly less irritation, ability to cry, ability to care about other’s feelings, sadness, erotic dreaming, creativity, surprise, anger, expression of their feelings, worry over things or situations, sexual pleasure, and interest in sex.6 A qualitative study in 2009 by Price et al also revealed that almost all depressed participants in the study described a reduction in their positive emotions, which they attributed to their drugs. Participants reported a reduction in a wide range of positive emotions, including happiness, enjoyment, excitement, anticipation, passion, love, affection, and enthusiasm. Yet, this may not be the only destiny for depressed patients; agomelatine, a new drug with a novel pharmacological action, was studied for its effects on emotional processing in healthy volunteers and was found to decrease subjective ratings of sadness, reduce recognition of sad facial expressions, and improve positive affective memory. Clinicians should therefore routinely ask patients about emotional side effects when they are assessing progress on antidepressants, and positive and negative emotions should simultaneously be taken into account in the early phases of treatment. _

1. Fredrickson BL. What good are positive emotions? Rev Gen Psychol. 1998;2: 300-319.
2. Fitzpatrick MR, Stalikas A. Positive emotions as generators of therapeutic change. J Psychother Integr. 2008;18(2):137-154.
3. Morrow J, Nolen-Hoeksema S. Effects of responses to depression on the remediation of depressive affect. J Pers Soc Psychol. 1990;58:519-527.
4. Enns MW, Cox BJ. Psychosocial and clinical predictors of symptom persistence vs remission in major depressive disorder. Can J Psychiatry. 2005;50:769-777.
5. Harmer CJ, Goodwin GM, Cowen PJ. Why do antidepressants take so long to work? A cognitive neuropsychological model of antidepressant drug action. Br J Psychiatry. 2009;195:102-108.
6. Opbroek A, Delgado PL, Laukes C, et al. Emotional blunting associated with SSRI-induced sexual dysfunction. Do SSRIs inhibit emotional responses? Int J Neuropsychopharmacol. 2002;5(2): 147-151.

11. M. A. Rangel, Mexico

Miguel Angel RANGEL, MD, PhD
Maestría en Psiquiatría
Universidad Autónoma de Querétaro
Colón 6 Edif. Columbus Despacho 105
Centro histórico Querétaro
Querétaro, 76000

Major depressive disorder (MDD) is a heterogeneous condition with complex neurobiological correlates that are still not fully understood, and it is one of the most prevalent mental illnesses. Current drug therapy is suboptimal. Response rates to a single antidepressant are generally considered to be 60%-70%, with over 80% of the drug affect accounted for by placebo effects. Remission appears in only 30%-40% of the depressed population. Unfortunately, about one-third of patients will not remit even after two to four pharmacotherapy trials. Vulnerability to relapse persists after remission, and this has been attributed to abnormal biases in the processing of emotional stimuli in limbic circuits.

Leaving aside the limited efficiency of antidepressants, evidence suggests that about 60% of improvement with an active antidepressant takes place during the first 2 weeks of treatment. Several meta-analyses have shown that early improvement after 1 or 2 weeks of treatment strongly predicts later treatment outcome.1 Better knowledge of the mechanisms involved in early treatment response may help us to optimize clinical decision-making and improve quality of life in our depressive patients. MDD is characterized by impaired cognitive and emotional processing,2 which is why modulation of emotional processing is an intended outcome of both pharmacological and psychological treatment.

Although studies show that antidepressants affect processing of both positive and negative emotions, recent studies suggest that changes in positive rather than negative emotions may be important in predicting recovery from depression. Patients with MDD usually report increased suppression of both negative and positive emotions.

Currently, recovery from a depressive episode is still measured by reduction of unpleasant symptoms and not restoration of a normal range of emotional experience. Drugs or psychotherapies actively targeting the positive affect (PA) or reward system may be more efficient in triggering recovery processes. Functional imaging suggests that anticipatory reward may localize to dopaminergic areas in the nucleus accumbens, ventral tegmental area, orbitofrontal cerebral cortex, and medial prefrontal cortex. Patients who have anhedonia are impaired in their ability to sustain up regulation of PA, and this is associated with reduced frontostriatal connectivity.

There has been an increase in the number of studies on positive emotions during the last few years.3 PA and negative affect (NA) have been defined as “subjective moods and feelings,” where PA represents pleasant engagement in positive feelings (eg, excitement, interest) and NA reflects distress and unpleasant reactions to the environment (eg, fear, shame).

PA and NA have only recently become a focus of pharmacological research. Harmer and colleagues were the first to suggest that serotonergic antidepressants may “constrain” emotional responses across both NA and PA. They showed that selective serotonin reuptake inhibitors (SSRIs) diminish the neural processing of both rewarding and aversive stimuli, and helped to explain the often reported emotional flattening effect of SSRIs.2

The ability to generate PA boosts (reward experience) from pleasant daily life events preserves mental health. Positive emotions also predict psychological resilience. Novel treatments that facilitate positive affective processing are required, and in this context, agomelatine has emerged as a promising option. Agomelatine is a new antidepressant with synergistic melatonergic agonism and 5-HT2c antagonism. This interaction underlies its efficacy in restoring circadian rhythms and mood; response rates of about 80% have been consistently reported across several trials. Furthermore, agomelatine increases dopamine and norepinephrine release in the limbic system, which would explain its perceived benefits for PA. Findings from the Harmer study in healthy volunteers demonstrated early effects of agomelatine on emotional processing, reduced subjective reports of sadness, improved positive affective memory, and modulation of emotion-potentiated startle response. Finally, agomelatine has additional advantages over other available antidepressants, and has exhibited improvements within a week of administration, in particular in mood, daytime functioning, and importantly, anhedonia. _

1. Henkel V, Seemüller F, Obermeier M, et al. Does early improvement triggered by antidepressants predict response/remission? Analysis of data from a naturalistic study on a large sample of inpatients with major depression. J Affect Disord. 2009;115:439(3)-449.
2. Harmer CJ, de Bodinat C, Dawson GR, et al. Agomelatine facilitates positive versus negative affectivity processing in healthy volunteer models. J Psychopharmacol. 2011;25(9):1159-1167.
3. Sin NL, Lyubomirsky S. Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis. J Clin Psychol. 2009;65:467-487.

12. M. Rufer, Switzerland

Michael RUFER, MD
Associate Professor of Psychosocial Medicine
Psychosomatics and Psychotherapy
Department of Psychiatry and Psychotherapy
UniversityHospital Zürich
Culmannstrasse 8, 8091 Zürich

From a psychotherapeutic perspective, the question should not be if, but rather when and how we take positive emotions into account while treating depressive patients. Just as health is more than the absence of disease, positive emotions are more than the absence of negative emotions. Although negative emotions are the main focus of research on depression, clinical practice shows that positive emotions should and can be specifically targeted with psychotherapeutic treatments. There are at least four good reasons as to why this is important: (i) reducing negative emotions does not automatically improve positive emotions; (ii) positive emotions can reduce negative emotions; (iii) positive emotions help resolve problems that play a role in the etiology and maintenance of depression; and (iv) positive emotions may protect against relapse and recurrence by improving quality of life and well-being. Furthermore, there is preliminary evidence that depressive symptoms are associated with difficulties in adaptively regulating positive emotions.1

However, interventions for enhancing positive emotions are not a panacea for the treatment of depression. The “when and how” is crucial for their success or failure. An attempt to simply encourage a depressed patient to “feel positive” will most likely have no effect or even worsen the symptomatology. The reasons are obvious: emotions cannot be invoked directly, and depressed patients in particular may interpret the failure of such an “intervention” as their own fault. Thus, we need therapeutic interventions that indirectly induce positive emotions and are integrated into a comprehensive treatment plan that includes interventions for both positive and negative emotions, as well as additional therapeutic aims selected on the basis of the patient’s specific needs. For example, in the acute phase of major depression, symptom-oriented interventions may be the best strategy. But for residual depressive symptoms, interventions focused on positive emotions and psychological well-being may yield the most beneficial effects, especially because the absence of psychological well-being seems to increase the risk of a relapse into depression.2

One concrete example of a psychotherapeutic strategy that works on positive states of mind is well-being therapy (WBT). WBT was developed in a clinical setting by Giovanni A. Fava,3 based on Carol Ryff’s cognitive model of psychological wellbeing.4 With regard to positive emotions, the aims are to encourage patients to systematically search for moments of well-being in daily life, identify thoughts and beliefs leading to premature interruption of well-being, engage in pleasant activities, and challenge dysfunctional beliefs or inappropriate expectations in certain domains of positive functioning.5

Best results may be achieved with a sequential combination of symptom- and well-being–oriented psychotherapeutic strategies. This may also be a promising option for anxiety disorders: while considerable alleviation of symptoms was achieved in a study of cognitive behavioral therapy for panic disorder, the vitality dimension of quality of life remained largely unchanged over time.6 Since deficiencies in energy and “pep” may create a vulnerability to future adverse events, additional interventions aimed at enhancing well-being may help to achieve more complete and long-lasting beneficial effects.

In conclusion, although the reduction of negative emotions is one important aim in the treatment of depression, positive emotions play a significant role as well. Targeting positive emotions may improve treatment of depression. In recent years, a growing number of psychotherapeutic interventions aimed at enhancing positive emotions have been developed.

However, both clinicians and researchers should pay attention to “when and how” interventions for positive emotions should be integrated into a comprehensive treatment plan for depression. _
1. Werner-Seidler A, Banks R, Dunn BD, Moulds ML. An investigation of the relationship between positive affect regulation and depression. Behav Res Ther. 2013; 51:46-56.
2. Wood AM, Joseph S. The absence of positive psychological (eudemonic) wellbeing as a risk factor for depression: a ten year cohort study. J Affect Disord. 2010;122:213-217.
3. Fava GA. Well-being therapy: conceptual and technical issues. Psychother Psychosom. 1999;68:171-179.
4. Ryff CD. Happiness is everything, or is it? Explorations on the meaning of psychological well-being. J Pers Soc Psychol. 1989;57:1069-1081.
5. Ruini C, Fava GA. Role of well-being therapy in achieving a balanced and individualized path to optimal functioning. Clin Psychol Psychother. 2012;19:291-304.
6. Rufer M, Albrecht R, Schmidt O, et al. Changes in quality of life following cognitive- behavioral group therapy for panic disorder. Eur Psychiatry. 2010;25:8-14.

13. A. B. Singh, Australia

School of Medicine, Deakin University, and
The Geelong Clinic, AUSTRALIA

Clinicians are trained to explore for positive emotions in depressive presentations, but only to the extent of screening for bipolarity. How many clinicians focus on positive emotions as part of their core management of unipolar major depression itself? Depressingly, I suspect only a minority do. I take positive emotions into account while treating depressive patients, not just as a nicety, but as a core element of both patient care and safety. Moreover, patients themselves rate the presence of “positive mental health” (eg, optimism, vigor, self-confidence) as the most important factor for them personally in determining remission from major depression.1

Traditional medical models have focused on distress, dysfunction, and mortality.2 This is understandable given that such concerns drive patients to seek help, but it is a model under change as societal expectations of physicians change. Additionally, the clinician’s relationship to society has changed, with fear of litigation sometimes shaping the focus more toward hazards than hopes.

Loss of enjoyment and disengagement from activities (social, recreational, and occupational) are cardinal problems impacting sufferers of depression, anhedonia being a core symptom in definitions of major depression. Depressed patients seem to have selective attention for “negative” emotions (sadness, fear, irritability, inadequacy), potentially perpetuating their dysphoria, apprehension, and disengagement.3 It is important to note that for some patients, such emotions are part of a grief adjustment process rather than a pathological state. Where there is a major depression-related selective attention for negative emotions, it is important not to inadvertently reinforce these cognitions by only questioning about such symptoms.

By the same token, one must not invalidate distress by excessively minimizing its importance during sessions with patients. A balance is needed—the “art” behind the science of clinical care.

Genuine ardent expression of intent to restore positive emotional capacity in patients can have profoundly beneficial therapeutic effects.4,5 Not only is engagement and treatment compliance fostered, but instilling hope may help reduce risk ideations.6 Once hedonic drive and energy begin to improve in severe depressive states, full recovery relies both on reengaging with and enjoying social, recreational, and occupational activities. Reinforcing these positive aspects of life may help prevent relapse during the maintenance phase of care.5

Positive emotions should be included in the assessment and management of depressive presentations as part of diagnostic formulation, risk management, and treatment of patients to a full emotional and functional recovery. As society increasingly considers well-being to be the key health outcome, failure to take positive emotions into account while treating depressive patients is in some ways missing the boat with regard to what patients and the broader community want from physicians in the modern era. If you are not already doing so, I encourage you to take positive emotions into account while treating depressed patients. _

1. Zimmerman M, McGlinchey JB, Posternak MA, Friedman M, Attiullah N, Boerescu D. How should remission from depression be defined? The depressed patient’s perspective. Am J Psychiatry. 2006;163:148-150.
2. Eisenberg L. Disease and illness. Distinctions between professional and popular ideas of sickness. Cult Med Psychiatry. 1977;1(1):9-23.
3. Maalouf FT, Clark L, Tavitian L, Sahakian BJ, Brent D, Phillips ML. Bias to negative emotions: A depression state-dependent marker in adolescent major depressive disorder. Psychiatry Res. 2012;198(1):28-33.
4. Sin NL, Lyubomirsky S. Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis. J Clin Psychol. 2009;65(5):467-487.
5. Dunn BD. Helping depressed clients reconnect to positive emotion experience: current insights and future directions. Clin Psychol Psychother. 2012;19:326-340.
6. Hanna FJ. Suicide and hope: the common ground. J Ment Health Counseling. 1991;13(4):459-472.

14. M. H. Tyal, Morocco

Mohamed Hachem TYAL, MD
88-90 Bd de l’Oasis
Quartier Oasis, Casablanca 20103

When dealing with the depressed patient, one can consider two complementary layers of reality. First of all, there is the objective, biological dimension, which among other things, involves genetic and biochemical factors such as serotonin or melatonin transporter proteins. Secondly, there is the subjective, psychoaffective dimension conveyed by the patient’s story, which the psychiatrist will listen to and analyze. On the one hand, this story tells the tale of all the breakups, grief, conflicts, and violence that the patient has lived through and the resultant anxiety, guilt, and loss of self-esteem that these life experiences engender, and on the other hand it also reveals the patient’s personal resources and ability to bounce back. Besides use of mere words, the depressed patient also conveys his or her story through tone of voice and body language. Indeed, the patient’s emotions flow through the story told.

The patient’s thoughts, conveyed by the narrative, will not be meaningfully put to use during current and future therapeutic care unless the psychiatrist takes into account the emotions, both negative and positive, that are expressed through this discourse. It is with this approach that one can best appreciate the reality of the depressed patient’s psychological suffering. Indeed, with any depressed patient, it is essential to seek to understand how the depressive state functions within the patient’s unique life story. It is important to find words to express the silent suffering of depression, to give it meaning. None of this is possible if the emotional dimension is distanced from the therapeutic approach. This is why, in a considerable number of cases, the use of the classic selective serotonin reuptake inhibitor (SSRI) antidepressants acts as a barrier to the treatment of depression, due to the significant impact these drugs can have on emotional state. Depression is not an accident that has to be overcome at any price by drugs.

One of the goals of treatment is precisely to allow patients to reclaim their existence and win back their self-esteem, a process which SSRIs, with their numbing of emotions, can repress. These drugs tend to estrange patients from reality, making life easier to deal with because anxiety, feelings, and sexuality are dulled, except that the patients become mere onlookers of their own life and their emotions are not integrated into their personality. By restoring a relative feeling of wellbeing, these antidepressants may prevent patients from contemplating the reasons for their suffering and thereby cause them to neglect the grieving process that is necessary to overcome the depression. Furthermore, these attenuated emotions may, at the same time, be displaced by somatic complaints (heart disease, etc), or they may resurface in a way that is much more dangerous to the integrity of self, in the form of delirium. _

15. A. M. Zain, Malaysia

Azhar Mohd. ZAIN MD, MPsychMed,
DipCogTh, AM
Professor of Psychiatry
Faculty of Medicine and Health Sciences
University of Putra
Senior Consultant Psychiatrist
Ampang Puteri Specialist Hospital
Kuala Lumpur, MALAYSIA

The diagnostic criteria for major depressive disorder (MDD), dysthymic disorder, and bipolar I disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are the same for children and adolescents as they are for adults, with some minor modifications. To make a diagnosis of a depressive disorder, the most defining symptom is depressed mood. DSM-IV describes this as depressed mood most of the day, nearly every day, indicated by subjective report or observation by others. The other defining symptom is anhedonia (loss of pleasure), which DSM-IV describes as markedly diminished interest or pleasure in all, or almost all, activities for most of the day, nearly every day.

In my clinical practice, I emphasize the importance of these two points or symptoms in order to diagnose MDD.When the symptoms present as continuous low mood and anhedonia not affected by environmental factors, this indicates biological abnormalities rather than purely psychological effects. Depressed mood that is involuntary and independent of environmental change has been investigated in several studies. Functional neuroimaging studies have most commonly associated depressed mood and sadness with abnormal neuronal activity in the medial prefrontal cortex, including the anterior cingulate cortex and orbitofrontal cortex.1 These areas receive innervations from serotonergic, norepinephrinergic, and dopaminergic pathways. As such, low levels of norepinephrine, serotonin, and dopamine may be associated with low mood. Reduced dopaminergic activity has been linked to decreased incentive motivation,2 anhedonia,3 and loss of interest.4 Increased functional dopaminergic activity has been linked to positive affect.5

In view of this, it is clinically important to view negative emotions, that is to say, low mood, anhedonia, and blunting of affect, as a diagnostic tool with which to make the correct diagnosis of biological depression, and to take into account the amount of positive emotion present during the first visit to establish the severity of MDD. The less positive emotion there is present, the more severe the MDD. Scales for measuring negative and positive emotions must be used so that an objective measurement is made and patients can see the lowering of negative emotions and the increase of positive emotions as they progress in their treatment. An example of such a scale would be the Snaith-Hamilton Pleasure Scale to measure anhedonia.6

In conclusion, MDD, dysthymic disorder, and bipolar I depressive disorder are all biological disorders, and changes in positive and negative emotions in patients with any of these conditions are due to biological abnormalities. As such, in the treatment of these patients, initial assessments and measurements of negative and positive emotions will help to determine treatment efficacy and progress and assist in establishing better compliance. An even better prognosis can be anticipated for patients who are able to experience and monitor the change from high to low levels of negative emotions and from low to high levels of positive emotions. _

1. Levesque M, Bedard A, Cossette M, Parent A. Novel aspects of the chemical anatomy of the striatum and its efferent projections. J Chem Neuroanat. 2003; 26:271-281.
2. Salamone JD, Correa M, Mingote S, Weber SM. Nucleus accumbens dopamine and the regulation of effort in food-seeking behaviour: implications for studies of natural motivation, psychiatry, and drug abuse. J J Pharmacol Exp Ther. 2003; 305:1-8.
3. Delgado PL. Depression: the case for a monoamine deficiency. J J Clin Psychiatry. 2000;61(suppl 6):7-11.
4. Willner P. Dopamine and depression: a review of recent evidence. I. Empirical studies. J Brain Res. 1983;287:211-224.
5. Depue RA, Collins PF. Neurobiology of the structure of personality: dopamine, facilitation of incentive motivation, and extraversion. J Behav Brain Sci. 1999;22:491- 569.
6. Nakonezny PA, Carmody TJ, Morris DW, Kurian BT, Trivedi MH. Psychometric evaluation of the Snaith-Hamilton pleasure scale in adult outpatients with major depressive disorder. J Int Clin Psychopharmacol. 2010;25:328-333.