Different people may define depression in different ways. Depression can be defined as a feeling of sadness that is uncomfortable, but does not interfere with daily life. Others define depression as a condition that causes severe depressive mood, loss appetite, inability to concentrate, and inability for one to function independently.
Even professionals may use different terms for depression. Kendall and co-workers noted in 1987 that the professional use of depression can be classified as symptom, syndrome, or nosologic disorder. . . . Depression can also be a sign or symptom. For example, sadness. Depression is a combination of symptoms and signs that are grouped together. . . . Although depression itself is a psychological disorder, it can also be found in secondary disorders. A thorough diagnostic procedure is required to determine if depression is a noosologic category. As such, it is likely that a particular nosologic entity will be etiologically distinct. There may be differences in treatment response, prognosis, course. We will be discussing this probable nosologic disorder.
Here is an outline of what will be discussed:
1. Definition of depression
A. Depression Symptoms
B. Comorbidity. Anxiety and Depression in Relationship
2. Diagnostic Classification
A. Major Depressive Symptoms
Chronic depression, or Dysthymic Disorder
C. Bipolar I Disorder
D. Bipolar II Disorder
E. Cyclothymic Disease
3. Exploratory categories of depressive disorders
A. Premenstrual Dysphoric Syndrome
B. Minor depression
C. Recurrent brief depressive disorder
D. Mixed anxiety-depressive disorder
4. Epidemiology
A. Frequency
– What percentage of the population is affected nationally?
– Worldwide Occurrence
B. Age differences
C. Ethnic and Sex Differences
D. Environmental Correlates
5. Etiological Theories for Depression
A. Mental models
– Psychoanalytic Methodologies
– Interpersonal Techniques
Cognitive perspectives
B. Ideas about biology
Analysis using genetic methods
– Neurotransmitter approaches
6. Protective factors
A. Aid from one’s social network
Dealing Mechanisms
DEFINITION DEPRESSION
A. SYMPTOMS of Depression
The fourth edition of Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) is required to define depression. The DSM-IV is an official system of diagnosis for depression. These criteria are the symptoms of depressive disorders. You must have at least five of the nine symptoms to be diagnosed with depression. These are (1) depressed mood, (2) decreased pleasure or interest; (3) significant weight loss/weight gain; (4) insomnia/hypersomnia; (5) agitation and (6) fatigue; (7) thoughts or feelings of guilt or worthlessness; (8) diminished concentration; and (9) thoughts or actions that could lead to death or suicide.
Different cultures and ages can cause depression symptoms. For example, children who are depressed may experience irritability and not sadness. It is possible that they do not make the weight loss or gain they expect. Older adults may experience depressive symptoms like loss of appetite, loss in interest, and thoughts about death. Depressive symptoms can also be reported in different cultures. One study showed that patients suffering from depression were more likely to report somatic symptoms than non-Jewish ones. Another study comparing depressive symptoms of college students from the United States, Taiwanese and Philippine found that Taiwanese students showed the lowest somatic symptoms as well as the highest affective symptoms. Similar symptoms were reported by other ethnicities. The expression of depression can be affected by one’s age or culture.
B. COMORBIDITY. The RELATIONSHIP OF DEPRESSION and ANXIETY
A combination of multiple disorders can be called comorbidity. While depression is generally recognized by clinicians and researchers as a separate disorder, there are many other disorders that can overlap with it. The relationship between anxiety disorders and depression is the focus of much current research. Given the high levels of comorbidity in both disorder types, this is not surprising. A study that looked at panic disorder patients found 63% also suffered from major depression. Negative affectivity could be one explanation for this overlap.
Clark and Watson described high levels of negative affectivity in 1984 as individuals who “are distressed and upset and have an adverse view of themselves”, while those with low levels are content, secure, and happy with their lives. Other characteristics of high negative affectivity include nervousness, tension, worry, anger, scorn, revulsion, guilt, self-dissatisfaction, rejectedness, and sadness.
Both depression and anxiety appear to have high levels of negativity. However, there are important differences between anxiety and depression. Depression and anxiety both have high levels of negative affect. But only depression has lower levels. People who are depressed tend to exhibit both high levels or lows of negative affect. However, people who are anxious may display more negative affect. The research on the link between depression and anxiety is progressing at an alarming pace.
What is the diagnosis?
The DSM-IV was mentioned earlier. The DSM-IV, North America’s most common classification scheme for mental disorders, is widely used. There are five types, all of which include depression, according to the DSM-IV. These include (1) Major Depressive Disorder; (2) Dysthymic Disorders; (3) Bipolar Disorder I Disorder; (4) Bipolar Disorder II Disorder; and, (5) Cyclothymic Disorder. Each classification has its own etiology, course and symptoms.
A. MAJOR DISORDER DEPRESSIVE
DSM-IV states that five symptoms are required to indicate Major Depressive Disorder (MDD) within a two-week period. The most common symptoms are depressed mood, which can last for up to 2 weeks.
MDD can also be classified by severity (i.e. mild, moderate, severe, without psychotic features or severe with psychotic characteristics), course (e.g. single episode versus repeated episodes), and presentation. Delusions, hallucinations, and false beliefs are some of the psychotic features of depression. Delusions, for instance, are people who believe they are dead. Psychomotor disturbances like excessive movement and stupor are some of the catatonic characteristics of depression. Melancholic symptoms include inability to feel pleasure, even when there are good things, and lack of interest in once pleasurable activities. MDD can be associated with severe impairments in many areas of life, including at work and home.
Dysthymia
Dysthymic Disorder refers to a depressed mood that lasts more than 2 years for adults and less than 1 year for children or teenagers. These depressive symptoms include: (1) low appetite or excessive eating; (2) insomnia or chronic fatigue; (3) low self-esteem and self-esteem; ((5) poor concentration or difficulty in making decisions; and (6) feelings despair. Dysthymic Disorder, which has fewer symptoms than MDD, is more commonly considered to be milder depression. It can also be as distressing as MDD and cause as much impairment. Dysthymic Disorder could also be combined with major depression episodes. A person suffering from Dysthymic Disorder and major depression is known as a “double-depression”. It is common for MDD and Dysthymia to co-occur.
Bipolar I disorder
Bipolar I disorder is characterised by mania. DSM-IV says that manic episodes are defined by an excessive, expansive, or irritable mood, which is persistent and distinct from normal elevated moods or irritable ones. At least three symptoms may be present during this period. These symptoms include an increase in self-esteem, decreased sleep requirements, unusual talkativeness, and (4) racing thoughts.
Bipolar I Disorder tends to be recurrent. DSM-IV says that more episodes are common in people who have had one manic episode.
Bipolar I Disorder sufferers can have manic episodes mixed with depression. Bipolar I Disorder patients may also exhibit melancholic, psychotic and catatonic symptoms.
D. BIPOLAR II DISEASE
Bipolar II Disorder can be described as hypomania mixed with depression. Hypomanic episodes have the same symptoms that manic episodes. Hypomanic episodes, however, are less severe and last only 4 days. Hypomanic episodes are more common than manic episodes. They can cause disruptions in daily functioning and may require hospitalization. Bipolar II Disorder can lead to depression just like that of MDD and Bipolar 1.
Cyclothymic Disorder
Cyclothymic disorders are characterised by hypomanic periods intermixed in depressive phases that are less severe than those experienced with MDD or Bipolar II Disorder. Cyclothymia can present with mood disturbances that change rapidly and are often accompanied by severe affective problems. These mood swings in Cyclothymia must last at least two years for adults, and at least one year for children and teenagers.
DSM-IV identifies four possible classifications which include depression. These classifications do not currently qualify as disorders. Additional information regarding factors such symptom presentation and etiology is required before they are considered disorders. These are serious problems that we discuss here even though they remain exploratory. They include: (1) Premenstrual Dysphoric Syndrome; (2) Minor Depressive disorder; (3) Recurrent Short Depressive Disorder; (4) Mixed Axiety-Depressive Condition.
EXPLORATORY CATERIES FOR DEPRESSIVE DISORDERS
Premenstrual Dysphoric Disorder
Premenstrual Dysphoric is characterized by the following symptoms: decreased interest, depressed mood and difficulty sleeping. These symptoms must have occurred in the last year of the woman’s luteal phase. This classification can have serious legal, social, and political ramifications for women, as many authors have noted. Some have suggested that women could be labeled as being more unstable or less stable than men if this classification is used as an initial diagnosis. These arguments keep Premenstrual Dysphoric Disorder classification a hot topic.
B. MINOR DEPRESSIVE DISEASE
Minor depressive disorder is characterised by fewer symptoms of depression than MDD. MDD sufferers are also affected less by impairment than those with Minor Depressive Disorder. A person must show two additional symptoms of Major Depressive Episodes in order to meet the criteria for Minor Depressive disorder. This classification would be a residual category that can only be used after all other mood disorders have been ruled.
C. RECURRENT BREF DEPRESSIVE DISEASE
Recurrent brief depressive disorder and MDD are fundamentally different in terms of their duration. Recurrent brief depressive disorder is characterised by depression episodes that do not meet the requirements for Major Depressive Episodes. Major depressive episodes require symptoms to last at minimum 2 weeks. Recurrent short depressive episodes can last for up to 2 weeks. However symptoms should not last more than 14 days. These brief episodes must also occur for at least one month over 12 months in order to qualify for Recurrent Brief Depression Disorder. Recurrent Brief Depressive Syndrome is similar to MDD due to its age at onset and family prevalence rates. It raises the question of whether it should be treated as a distinct disorder.
D. MIXED-ANXIETY DEPRESSIVE DISORDER
A mixed anxiety-depressed category was born out of the realization that many people with symptoms of depression and anxiety are not eligible for DSM anxiety, but are still severely affected by their problems.
Mixed Anxiety-Depressive disorder is defined as a condition that causes a persistent, depressed mood lasting at least one month. It also includes at least four other symptoms that are primarily anxiety related (e.g. worry, panic, mind going blank), This disorder would allow for the treatment of many people suffering from anxiety and depression. However, it would not be limited to those who are already diagnosed. This classification could be used to classify people with both anxiety and depression using more specific assessment methods.
The branch of medical science that studies the patterns, causes, and effects of diseases and health conditions in certain populations is known as epidemiology.
Epidemiology is the study of the prevalence and incidence rate of disorders within a population. A prevalence rate is the number of people affected by a disorder in a specific time period. This could be the percentage of MDD-positive people within a one year period. Incidence rate is the number or number of cases of a disorder that occur in a specific time frame (e.g., Dysthymic Disorder was diagnosed in April 1996). Epidemiological information is important to understand the possible causes and correlations of depression.
A. OCCURRENCE
1. NATIONAL PRIVILEGE
Two large-scale surveys of American psychopathology recently found that the prevalence rates for depression were different in each country. The Epidemiologic Catchment area (ECA), a study that used diagnostic criteria from the 3rd Edition DSM-III-R, examined depression rates at five locations: New Haven (Baltimore), St. Louis (St. Louis), Los Angeles (Durham), and Durham. The ECA study showed that lifetime major depression prevalence (i.e., number of people suffering from major depression at any given time) was 4.9% and lifetime dysthymia prevalence to be 3.2%. However, the National Comorbidity Surveys (NCS), which reported higher rates of prevalence, found 14.9% lifetime major depression and 6.4% dysthymia. The differences between the studies might be due to the difference in the assessment tools used, slightly different diagnostic criteria used and different age ranges. (e.g., the ECA study was 18 years or older, while NCS ranged from age 15 to 54). The ECA study showed that the lifetime prevalence rate of bipolar disorder was much lower at.8% and.5% respectively. The NCS lifetime prevalence of manic episodes was slightly higher at 1.6 %. These epidemiological studies found that mood disorders in America are fairly common, despite discrepancies in their rates.
2. INTERNATIONAL PRVALENCE
Numerous studies have looked at the prevalence of major depressive disorder in communities outside of the United States. Lifetime prevalence rates in different countries vary widely. The lowest is 3.3% for Seoul, while the highest is 15.1% for New Zealand residents between 25 and 46. Although these differences could be indicative of true differences in depression incidence, they may also reflect cultural differences in how instruments are used to assess the disorder. Other factors like different age groups and differences in sample ages might also contribute to this variation. Bipolar illness prevalence has varied from.07% to 7% in Sweden according to reports. However, most studies show that the incidence of bipolar illness is approximately 1% according to data from NCS or ECA.
B. Age disparities
ECA also provided data on depression incidence rates for different age groups. Major depression was most common in men aged 18-29. Men aged 45 years and over saw a significant decline in their incidence. Women were more likely to experience major depression if they were between the ages of 30 and 44. This trend continued until the age of 65.
C. SEX & ETHNIC DISORDERS
ECA’s study shows that women are twice as likely to have a lifetime of major depression, disthymia, and other mood disorders than men. The lifetime rates of major depression, dysthymia, and all mood disorders in women were respectively 7.0%, 4.1% and 10.2%. Men’s rates were 2.6%, 2.5 % and 5.2%. These differences can be found in a wide range of ethnic groups, including African Americans, Hispanics, Caucasians, even if there are differences in income, education, and occupations. Other countries have also been shown to show sex differences. Sex differences in depression are one of the most reliable findings from studies. However, bipolar disorder rates are not consistent.
Although there is a difference between sexes in depression incidence, there are still some differences across these groups.
ECA research found that Caucasians, Hispanics and African Americans had higher levels of Major Depressions and Dysthymias than did African Americans. However, the bipolar disorders rates were similar in all three groups.
D. ENVIRONMENTAL COMRRELATES
ECA also looked at a variety of environmental factors that can contribute to depression and bipolar disorder. The 1-year prevalence rate of major depression in people who have been separated or divorced was higher than that for those who are not currently married (2.1%), or widowed (2.1%). However, the rates of bipolar disorder patients were almost identical (1.2%) and 1.6% respectively. The unemployed had a higher rate of major depression than those who were employed (3.4% versus 2.2%), while the rate for bipolar disorder sufferers was 1.1% versus 1.0%. The ECA study also found that white-collar workers had higher rates of major depression than those who have at least 12 years’ education. However, those earning $15,000 or more per year were less likely to experience depression. The major depression findings also showed that bipolar disorders were more common among people with an annual income of $15,000 or higher. Bipolar disorders were also more common among non-white-collar workers who have less than 12 years education. These socioeconomic distinctions were relatively small.
ETIOLOGICAL DEPRESSION THEORIES
There are many psychological theories that explain depression. These theories can be classified as cognitive, interpersonal, or psychoanalytic.
A. PSYCHOLOGICAL THOUGHTS
1. PSYCHOANALYTIC APROACHES
Karl Abraham, Sigmund Freud’s student and the first psychoanalytic writer to discuss the etiology behind depression was Karl Abraham. Freud’s and Abraham’s theories are similar, as one would expect. Freud believed some people were predisposed to depression. Abraham also believed this. Abraham explained that the predisposition to depression was caused by anatomical abnormalities that could allow someone to experience a high level of oral romance. Freud defined this as a predisposition to narcissistic self-love (i.e., self-love that is so close to the object) Zweiten, they believed that having a predisposition for depression did not cause it. For someone to experience depression, they must also have lost a loved one (e.g., death or rejection).
Although these similarities are apparent, they differ slightly on the mechanism by which depression happens after a loss. Abraham believes that a loss of a beloved object triggers a return to the oral stage in psychosexual development. It is intended to have three main purposes: (1) increase pleasure; (2) hold on to an object by oral incorporation; (3) discharge aggressive impulses. These symptoms are most apparent in excessive or inadequate eating. Freud saw different implications when a loved one is lost. The lost object represented the self and was therefore a narcissistic choice. Anger and depression are triggered by this loss. Introjection involves bringing the energy associated to these negative feelings inward. Freud describes depression as “anger turning inward”. Freud saw the difference in sadness and true depression as the difference between “this Is Awful” and “I Am Awful.” Freud also extended his theory in order to explain bipolar disorder symptoms like mania. Freud suggested that the anger and depression caused by the loss or destruction of an object could be overcome. This would allow the negative energy to be used for other purposes. Bipolar disorder patients have the ability to use their free energy to zealously seek out new objects.
The role of the superego has been a focus for psychoanalytic experts in recent years. For example, some theorists suggest that guilt is a distinguishable state from shame, apathy or resentment. Because guilt is a result only of an intrapsychic struggle between the superegos, it is inevitable that depression is also associated with the superego. This has led to two types of depression, anaclitic (or introjective) – based on the differences in the etiological focus. Anaclitic depression can be characterized by feeling helpless, insecure, and unloved.
Anaclitic depression can be linked to the early stages of development. It is most closely related with Freud and Abraham’s theories. Introjective depression, on the other hand, focuses more on feeling unworthy and failing to meet expectations and standards. It is more closely linked to later stages and works by later psychoanalytic theorists. Although some aspects of psychoanalytic theories have been criticised for not being empirically validated, empirical evidence has shown that the distinction between anaclitic or introjectire depressions is valid. Bipolar disorder development has been explained by psychoanalytic theorists. Melanie Klein is the most prominent of these theorists, as she expanded on Freud’s work.
2. INTERPERSONAL AAPPROACHES
The interplay of depression and the relationships between depressed people and their loved ones is the focus of interpersonal approaches to the maintenance and etiology. This area of empirical research has been explored in many directions. Researches have examined the role that social skills play in depression. For instance, they ask whether depression sufferers lack social skills. Other research has focused on the types and effects of depressed persons’ communications (e.g. hopelessness, sadness) and how they affect others. Depressed people may be perceived as averse by others, and they may avoid these people, which can lead to loneliness and isolation. Other studies focus on the interaction between depression, stress, and social support. These lines of research all found support. Interpersonal research also supports the idea that depression can be caused by many factors interconnected.
The theory behind depression stems from disruptions in interpersonal relationships. This is the consensus of much of the research. Many people with depression seek social support. If that does not relieve the sadness, additional support may be sought. This increased support-seeking can, paradoxically, lead to the exclusion of those who were supportive. This is because when people feel they have exhausted their support, they tend to withdraw from those who are supportive.
Research on the interplay between interpersonal and etiology factors of bipolar disorder has not been as extensive as that done for unipolar disorders. However, people with both types depressive disorders have difficulty retaining support. In fact, bipolar disorder sufferers perceived that their social support was less accessible and less effective than those in a larger community. As the illness progressed, so did perceptions about social support availability. It seems that both bipolar and unipolar depression disorders are affected by social support.
3. COGNITIVE APROACHES
Cognitive approaches are currently the most well-studied theories about the etiology for depression. Aaron Beck, a 1967 researcher, proposed one of the most important theories. Beck believed that every individual has cognitive structures, called schemas, that govern how information is interpreted and attended to. Our interactions with the world around us in childhood determine these schemas. A child who is continually criticized might believe that she is worthless. In this situation, she might start to consider every failure as proof that she is worthless. If she does not change her negative information processing, it will remain an enduring part in her cognitive organization, which is a schema. This schema will be activated by any negative experience, such as a bad grade or a failure, and it will lead to depression (e.g. “I’m no good.”). Beck said that depressed people have a cognitive trifecta of negative thoughts about their future, the world and themselves as a result. He extended his argument further to include manic episodes of bipolar disorder. Beck said that these phases are marked by an irrationally optimistic triad of thoughts about oneself and the world. As with the bipolar depressive syndrome’s depressive trifecta, manic symptoms in bipolar disorders could be similar to mania. These include inflated self-esteem and an extremely high mood.
There is consensus that depression can occur from many factors. Some psychologists believe dysfunctional cognitions may only be responsible for a certain subset of depressive symptoms. This subtype of depression is called “negative cognition”. It is caused either by Aaron Beck’s types of schemas or dysfunctional attributes patterns. People who are depressed tend to be more responsible for the occurrence of bad events than they are for positive ones. This dysfunctional pattern of attribution can cause hopelessness and a negative component of depression.
B. BIOLOGICAL THOUGHTS
There are many biologically-based theories about depression. However, there are two main approaches to it: genetic and neurotransmitter.
1. GENETIC METHODS
Genetic studies have shown that depression can be caused when genes are passed on to children who are more susceptible to it. This approach is illustrated by three types of studies: twin studies, family studies, and adoption studies. These studies include twin studies, adoption studies, and family studies. A typical family study involves interviewing families that have a depressed member to find out if any other members of the family have had or are currently experiencing an affective disorder. Twin studies compare the concordance rates of affective disorder among monozygotic or dizygotic twins. Monozygotic siblings have identical genetics, so concordances of depression between monozygotic and dizygotic couples should be greater than for dizygotic. There are two main strategies used in adoption studies. The first compares depressive disorders in adopted children whose biological parents have and do not have affective disorders. The second compares the rates of depression in adopted children who have had affective disordered parents and those without. Because of the lower environmental effects on affective disorders, adoption studies are more advantageous than twin and family studies. Adoption studies are not the best way to investigate genetic factors in depression. It is also the most difficult method because it is very difficult to obtain records on both adoptees’ biological parents.
Despite differences in design, all three genetic approaches to depression’s etiology have produced similar results. Depression is at least partially heritable. Recent research has shown that affective disorders rates among unipolar-disordered first-degree relatives range from 11.8% to 32.2%. Rates among bipolardisordered persons’ first-degree relations ranged from 10.6% – 33.1%. Rates of affective disorders in first-degree relatives were ranging from 4.8% to 6.3. Concordance rates among twins of unipolar, bipolar, and schizophrenia ranged between.04 and 1. for monozygotic couples and 0.0 and.43 for dizygotic. The majority of reviewed studies reported no concordance in dizygotic. While genetic studies clearly indicate that depression may have a genetic component it is still not clear how and why.
2. NEUROTRANSMITTER PROCEDURES
Two monoamine neurotransmitters have been identified as the etiology of unipolar depression. They are serotonin (5 HT) and norepinephrine (5 HT). Initial research suggested that depression could be caused by a lack NE in brains. Then, later, it was suggested that the brain may lack both NE as well as 5-HT. These hypotheses have several problems. (1) Although antidepressants can reduce monoamine levels within hours, the effect on depression is not apparent for weeks. (2) Monoamine levels are not affected by some drugs that alleviate depression. (3) Monoamine-boosting drugs do not relieve depression. Researchers have focused their efforts on investigating the complex relationships between neurotransmitters, depression and other neurotransmitters. Recent studies have focused on receptor site hyposensitivity and the relationship between NE-5HT and each other. 5-HT, the neurotransmitter Dopamine (DA),
Bipolar depression research has been influenced by brain chemistry. This is similar to unipolar depression research. Initial research suggested that bipolar disorders were caused by excessive neurotransmitters NE or 5-HT. This was contrary to depression.
This hypothesis was not without problems. For example, lithium, which is the most effective medical treatment for bipolar disorder, seems to be able to control both depression AND mania. (2) Both depression and mania could also be characterized with lower levels of 5-HT. Researchers studying bipolar disorder have also begun to investigate more complex relationships between neurotransmitters and bipolar depression. Researchers also looked into interactions between 5-HT/DA and interactions between NE/DA, and receptor-site hypersensitivity, similar to the unipolar disorder research. These investigations offer promising research opportunities in understanding the multifaceted causes of depression. Both bipolar and unipolar depressions are caused by biology and psychology.
PROTECTIVE ACTORS
Research has focused on ways to reduce depression and the duration of episodes. Social support and coping strategies are two of the most studied protective factors.
A. PEOPLE WHO OFFER AID OR COMFORT IN TIMES OF NEED
Social support can have many facets. Social support can also be defined as the number and quality of people one can trust for help. The amount of support received can be considered social support, regardless of the number or individuals receiving it. Additionally, it is possible to think of socially supportive relationships as being a continuum in quality, from very low to very high. This has helped us to understand the connections between social support and depression.
People who regularly have contact with supportive social figures are less likely than others to experience mental health problems such as depression. People who feel supported by others are less likely than those who don’t have much support. A support network of family members and friends can help people with depression to succeed in their treatment. It is important that these relationships are of high quality for treatment. For example, a study showed that people suffering from depression who have good relationships with their confidants needed less treatment than those who had low quality relationships.
Social support for bipolar disorder sufferers has not been as extensively studied as those for unipolar depression. However, bipolar disorder sufferers can still benefit from social support. One study found that people with bipolar disorder who have a lot of social support had fewer symptoms, greater social adjustment and overall better functioning.
B. COPIING STYLES
The two main types of approaches to dealing with stressors are avoidance strategies and strategy. Approach strategies consist of identifying the problem and devising solutions. Then, they are implemented. Avoidance strategies include avoiding thinking about the problem and imagining a life that is free from it. Approach strategies can help people manage stressors that may otherwise lead to depression. People who are depressed have a better chance of obtaining treatment if they use approach strategies. Conversely, those who try to avoid stress by using strategies to cope may be more likely to be depressed.
Unfortunately, there is not much research on bipolar depression symptoms and coping styles. However, a recent study on the coping styles of people with bipolar disorder found that those who avoid coping are more likely to have poor functioning. These relationships may be similar between coping styles, bipolar disorder and coping and unipolar depression disorders.
