Dear Marita, 

If you do not believe in e.g. BDI you lack experience of this kind of  well validated instrument.  Not everyone can spend 7 years in psychoanalysis. 

yes, for sure. Using DASS-21 scale, Mothers of children with Autism frequently reported: "I felt down-hearted and blue, inability to experience positive feeling, I felt that life was meaningless, I was unable to become enthusiastic about anything, I felt that I had nothing to look forward to".

The least frequently reported symptoms by mothers are" " difficult to work up the initiative to do things, I felt I wasn’t worth much as a person"

In contrary, in depressive patients with schizophrenia, they report " I felt I wasn’t worth much as a person,  It is difficult to work up the initiative to do things" as well as other symptoms.

It is a small sample, but there is a clear constant pattern, I will try to enlarge the sample size and make further investigations.

Thak you so much

yes, they are differ according to different situations, However, the whole picture is almost typical

Thank you so much my professor "Shaher Hamaideh"

While  depressed some do not eat (Finns eat too much so the scale was revised), some have difficulties falling  asleep, some wake up too early, some think they are no good and so on. It varies from person to person which symptom is on the surface.  And some have the so called "smiling depression" (0-3 points on BDI) 

Thank you so much Dr Ewalds-Kvist, but I wonder if some populations may have specific sets of depressive symptoms based on their life situations!

Different kinds of losses produce individual answers but you can of course also "copy" symptoms from the environment. BDI inventory though takes into account many different symptoms and the sum of the whole is more than the separate symptoms

This is very interesting and makes sense to me.  Depression is thought to result from an interaction between genetic predisposition and adverse life circumstances.  It is intuitively logical that the life circumstances of carers of autistic children may precipitate a sense of sadness and lack of meaning, because these individuals are receiving very little emotional reward (e.g., affection) from their child.  These particular circumstances are unlikely to cast doubt on the carer's sense of self-efficacy and sense of value, because they are performing a crucial and demanding role in caring for the child every day. 

One interesting feature of the depression associated with adverse outcome in cardiac patients is that it isn't the model familiar to psychiatry – the Beck cognitive triad. Instead, it is characterised by anhedonia in the absence of the cognitive features (what my wife calls "thoughts that aren't your friends"). We found the the Hospital Anxiety and Depression scale (which is a horrible mixup of nonspecific symptoms and doesn't even have a depression item!) predicted subsequent cardiac events while the short form of the Beck depression inventory (carefully aligned to DSM-IV) did not! 

Of course I'm away from my desk, but I'll post a couple of papers by my colleague Frank Doyle that strongly suggest that there's at least one type of depression that we haven't yet properly characterised from the phenomenological point of view. In fact, the best thing to do is to browse Frank's papers. He's got a major interest in this area:

https://www.researchgate.net/profile/Frank_Doyle/publications

Just to add to Béatrice's point: the Beck was originally developed as a case formulation instrument, not a screen. Its purpose was to define the particular complaint of the person as the basis for setting treatment goals. So its underlying rationale is that different people can become depressed in different ways. Or rather that there are different configurations of symptoms that get called depression because they share the features of depressed mood or anhedonia. But from the cognitive point of view they can have arrived there in quite different ways.

Thank you so much Dr Phillips for the nice interpretation, I also think that those mothers did not report "difficult to work up the initiative to do things" because they are obligated to respond immediately to child's behaviors, and they did not report "I felt I wasn’t worth much as a person" because they have a great role in providing care for their child, which may enhance their self-worth.

Prof Conroy, thank you so much for your valuable information. I am waiting impatiently to see the papers from your colleague Frank Doyle that "strongly suggest that there's at least one type of depression that we haven't yet properly characterised from the phenomenological point of view" when you return to your desk.

Best Regards

Ahmad.

How different symptoms can be you see looking at depressive children: most of them, especially the boys are aggressive in first sight, so that they first often treated like boys with social misbehavior. And when the (wrong) diagnosis is AD(H)D, then they are getting more and more depressive by treating with methylphenidate (some getting even suicidal ideas). And in the end of the day the angry boys (not birds!) are regognised as depressive - worse then before, because of the additional stigmatisations.... 

Yes Dr Henss, It's crucial to understand what's really behind aggressive behaviors of children,  Ritalin and Concerta for management of  ADHD won't work if a child's aggressive behavior is caused by depression. But I think it is the fault of the doctor who misdiagnosed the child and does not think of  reexamining the diagnosis even when the treatment doesn't work!

I have to agree with all of you even  if my view point differs. I'm an analyst and have seen all kinds of depressions during 40 years of carrier also as psychyaitrist and psychotherapist. With your depressive patient you only have to be there. But before you choose a patient in therapy you must choose those who cannot be treated for hospiitalysation or medical treatment.. It is'not so easy. You surely know that analysts never use a scale only their analytic instrument. I don't believe in scales!?

Thanks Dr Torsti-Hagman, I emphasized on your point of view in one of my papers

http://www.sciepub.com/portal/downloads?doi=10.12691/ajnr-3-1-2&filename=ajnr-3-1-2.pdf

Please see page (2). "For assessment of depression, using self-evaluation instrument, however, is not adequate; it is important to use a semi-structured clinical interview, especially, for those patients who have scores higher than the cut-off score on self-evaluation instrument which indicates presence of depression".

However, I just want to inquire about the "unusual discovered pattern" in my data, I will let you know if the same pattern will still the same after obtaining a large sample. I think it will be fine to "believe in scales" when a large representative sample is included!

Dear Marita, 

If you do not believe in e.g. BDI you lack experience of this kind of  well validated instrument.  Not everyone can spend 7 years in psychoanalysis. 

I believe there is ample evidence to indicate that the BDI and other self-report depression inventories provide reliable indices of overall levels of depressive symptoms.  However, I have often wondered about the wording of some of the items, which ask people to assess how they are feeling/thinking "now" compared to how they "usually" feel/think.  To me, this is problematic for people who experience chronic depression.  Their "usual" comparative baseline is actually depressed.  They could theoretically answer all questions honestly and generate a score that is in the non-depressed range.  Has anyone else ever wondered about this?

I have to say that I think mother's of children with autism suffer in silence, more often than not.  I am a mother of a son with autism; I am also diagnosed with Major Depressive Disorder (MDD).  When we discovered Thomas was autistic, I was devastated.  It took me some time to come to terms with his disorder.  I felt that it was my fault that he had developed the disorder.  Depressive symptoms do vary widely between mothers of children with autism.  However, if you were to compare what information you have collected with that of females with depression, I believe you will find the symptoms of depression in mothers and non-mothers, will be close to the same.

I agree with you dr Phillips, you know that one of DSM criteria for diagnosis of major depression is "Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day," this indicates a need to compare between the current and previous level of anhedonia. But this is useful for diagnosing the individual for the first time, not for assessment of patients with chronic depression.

Dear Onitra, I feel some inconsistencies between your sentence "Depressive symptoms do vary widely between mothers of children with autism" and your sentence "if you were to compare what information you have collected with that of females with depression, I believe you will find the symptoms of depression in mothers and non-mothers, will be close to the same"

Could you please explain more.

Dear Wendy, 

Yes, you have to indicate how you felt the last 2 weeks. My students have wondered about this. 

"Depressive symptoms do vary widely between mothers of children with autism"...

"if you were to compare what information you have collected with that of females with depression, I believe you will find the symptoms of depression in mothers and non-mothers, will be close to the same"

Indeed, it does seem like an oxymoron.  My apologies.  Mother's of children with autism, and non-mothers, suffer similar symptoms of depression.  However, at the same time, they differ.  I say this because I know a few mom's and non-mom's who suffer from depression.  One lady has anger symptoms associated with her depression.  Another lady, a mom, is quite the reverse; however, the other symptoms are very similar to those of the non-mom.  Another young lady exhibits symptoms of depression in a completely different way.  She lives in complete denial of her mental illness.  She does not understand that she is depressed, although others around her can see it clearly.  

The symptoms of MDD are exhibited differently in each of the three ladies.  The mother of an autistic child has only recently sought treatment, while the other two ladies refuse treatment because they believe they are "fine."  

Dear Onitra, thank you so much for your explanation. I got your idea now. You can not imagine how much I suffer from young ladies who are in the "denial phase". Surprisingly, some of them rated the items related to depression very high, but still denying that they are depressed! Also, some of them even deny their child diagnosis "with autism" although the child is currently in an Autism center! I think we should recognize denial as a normal phase in grieving process for every human being.

Denial is very common and very disturbing

Dear Ahmad

Without referring specifically to depression experienced by people with other health problems, I would draw your attention to arguments put forward with respect to what has been termed endogenous (organic) and exogenous(reactive) depression. Many clinicians will point to differences in the 'experience' of depressive symptoms in relation to these typologies. For instance, it is suggested that people with endogenous depression will experience late sleep disturbance while those with a reactive depression will experience this as early onset sleep disturbance. The idea being that they have deteriorated in their condition/worry/etc across the course of the day. You will also see accounts of some people demonstrating great retardation versus others who display greater agitation, etc.  I wish you well with your work. Kate

Thank you so much Dr Moore

You should refer to the DSM-5 for more specific information regarding the severity and depressive symptoms as it relates to women. Gender differences may be an area to analyze as the fathers of these same children with autism may experience depression differently. The experience of depression in this specific population of women may be  an area of research that needs more empirical study. Go and do it! 

Dear Beatrice. That's right you know but here is the difference between our insights. The psychoanalytical and many other means of trying to understand or calculate.

Best Marita

Very familiar to me. I have been in the orthodox Finnish psychoanalysis for 7 years!

Sorry Beatrice I did not know: Marita

yes.SYMPTOMS DO DIFFER CULTURALLY.eastern AND wESTERN CULTURE DIFFER IN THEIR EXPRESSION OF EMOTIONS SO ALSO RELIGIOUS AFFILIATION ALSO IS A SIGNIFICANT VARIABLE.sEX DIFFERENCES TOO EXIST.bUT DIFFERENCES ARE SUBTLE AND CAN BE NOTICED AFTER CAREFUL SCRUTINY.

Ramdas: Can we have some references on this? It's an important claim.

Dr. Ronan Michael Conroy;  

Upon reading your post, I did a little bit of research and discovered the following .pdf.  I think it will interest you and everyone else. 

Truly, non-Western cultures view depression differently than us Westerners.  In some cultures, those suffering depression are shamed by their families.  This is very unfortunate for the individual suffering this mental illness.  It is also no different if they migrate to the U.S.  The family looks at depression as more of a demon, than an illness.  I will continue to do some research on this, and touch base with you as soon as I locate what I am looking for. 

http://psych.stanford.edu/~tsailab/PDF/Understanding%20Depression%20Across%20Cultures.pdf 

I suggest looking at the Royal College of Psychiatry special interest group on transcultural psychiatry . http://www.rcpsych.ac.uk/workinpsychiatry/specialinterestgroups/transculturalpsychiatry.aspx

My own experience was of trying to translate a child behaviour checklist into Kiswahili. The trouble was that the behaviours that were quite common and unremarkable in European or US children (like being cheeky to parents or swearing) were so rare and serious that they had a totally different significance in Kenyan cultures. 

Hello again! As I have studied and later done in my treatments both therapies and analysis; we diagnose as exact as we can the structure of the patient in our interviews there is e.g, important to notice if he is addressing his speech to the interviewer as a person or as a symbiotic self object. Kernberg has written good books on this ability. 

Yes!

I'd like to join others in saying "Yes" to your question, Ahmad.

Indeed depression is a universal phenomenon and there are subtypes of depression. However, from the perspective of multicultural psychotherapy and international/global psychology, there are differences in one’s symptom manifestations, cultural explanations, and impact of depression on oneself and one’s intimates, depending on one’s cultural identification, acculturation to the Western cultural worldviews, and diverse backgrounds (Falicov, 2014; McGoldrick et al., 2005; Sue & Sue, 2013).

In terms of treatment, there are also differences in one's expectations of the treatment goals, processes and relationship with the healer (Cheung, 2009; Hong & Ham, 2001).

DSM-5 has provided an excellent outline for cultural formulation (OCF) and Cultural Formulation Interview (CFI).

Thank you so much Prof Cheung, I think that "the cultural explanations, and impact of depression on oneself and one’s intimates culture" have a great role in explanation of my results. I enlarged my sample and discovered additional supported evidences. Today, many mothers of children with ASD completed DASS, most of them read these sentences " I felt I wasn’t worth much as a person" and  "It is difficult to work up the initiative to do things"  in load voice with emphasizing: "this has never, and will never happen for me!", despite rating other depressive symptoms as "frequently occurring". Additional explanation by other scholars also can help me to interpret the results.

 Thank you all...

Kind regards...

Thanks for your sharing, Ahmad. Could cultural expectations of a mother influence their answers (e.g., they would want to look good in the eyes of others, and/or they might fear shame for not doing a good job as a mother, and/or they felt the need to defend themselves, etc.)?

Interestingly, in Arab cultures women hide their feeling of inadequacy, or being unable to do their duties as a wife or a mother. They would want to look good in the eyes of their husbands and the community, because they feel shame when their husband or the community believe that the spouse should look for another wife! it is well-known that Arab men are permitted to marry more than one wife!

There are cultural explanations for different depressive symptom manifestations in different cultures. In DSM-5, there are sections on Cultural Concepts of Distress (pp. 758-759, 833-837). For example, Shenjing Shuarirou (Neurasthenia) refers to "weakness of the nervous system in Mandarin Chinese" with symptoms of physical weakness, excitement, nervous pain, and sleep disturbance, etc.

I agree completely with you.

However, I disagree with these explanations. 

Depression, seen by an internist, includes numerous, various, sometime opposite features, psychic and somatic as well. Each depressive patient has an unique, personal, sometimes variable constellation of signs. Similarity through generations is observed only for alcoholism and digestive functional troubles.

These allow a means to gather apparently different psychic syndromes, frequently poorly defined

Besides, genetic transmission of depression is largely demonstrated since times.

Therefore, it's not surprising that mother and child present with different masks of the same cause.

Dear Bernard,

Thanks for your comments and attached document! I appreciated your insightful input into the complexity of depression and its biological/genetical causes.

I discussed the question from a multicultural psychotherapy perspective because I deem it immensely important when working with clients who may identify with a collectivist worldview (e.g., in the Middle East) as compared to an individualist worldview (espoused by individuals in some Western countries), and this cultural perspective has very often been overlooked.

Warm regards,

Stephen

Dear Stephen

I  see we share some conceptions which seem to me evident but not to those that I name maliciously "paleo-psychiatrists", stuck in psychogenic conceptions.

I agree completely with cultural modulations, the nature of which remains, nowadays, unknown. I have noticed numerous studies about this, especially by the WHO.

I have been working on Arabs, Bantus and Vietnamese. Relative frequency of signs differ but not the signs themselves, especially somatic ones. They are therefore of paramount importance for understanding and identifying depression.

Moreover, efficiency of antidepressants fails to be different.

I regret that circumstances have impeded translation of my book, which is much more detailed with a large bibliography.

Hertzliche grüsse!

Dear Bernard,

Thanks for your interesting discussion! I appreciated your knowledge and expertise!

Like other mental health professionals, I'd see the the interplay of genetics, stress, and environment (e.g., cultural background and experiences, etc.) in depression because humans are bio-psychosocial beings. 

In providing mental health services to diverse patients for a long time, I've witnessed not only their similar signs, but also their different symptoms. For example, a lot of East Asian patients express the symptoms of "boredom", and "aches and pains" in addition to the typical symptoms of depressed mood, loss of interest in their pleasurable activities, and changes in appetite, sleep pattern, energy levels, etc.

Dr. Keh-Ming Lin and others have done extensive research on culture and pharmacology. Some of his articles may interest you.

Warmest regards,

Stephen

http://cretscmhd.psych.ucla.edu/healthfair/PDF%20articles%20for%20fact%20sheet%20linking/MentalHealthIssues_API.pdf

http://www.sciencedirect.com/science/article/pii/S0193953X05702458