canhelp patients understand the triggers for depressive disorder and how to deal with them. and it should have greater influence on the discussions that guideline treatment in depressive disorder. Depression as a response to stressors Some years ago the philosopher and physician Carl Elliot wondered what might be wrong Verlukast with using antidepressants to treat a melancholy Sisyphus sentenced in perpetuity to pushing a big rock up a steep hill only to see it roll back down again. Elliot concluded that to modify the affective response of Sisyphus with a drug was to ignore “certain larger aspects of his predicament connected to boulders mountains and eternity.”3 Elliot’s concerns-that the use of antidepressants fails to deal with the context in which the depression occurs-are given impetus by data showing that nearly 70% Verlukast of depressive episodes are triggered by psychosocial stressors.4 Moreover it is increasingly likely that many of the changes in brain chemistry that feature in depressive disorder and that are targeted by antidepressants follow from increased production of cortisol in response to stress.5 It is acknowledged that genetic predisposition6 and individual vulnerability stemming from adversity in early life7 predict a depressed response to stressors. And there is some evidence for a kindling effect whereby stressors provoke depressive disorder at ever lower thresholds as the number of episodes mounts.8 Also melancholic depression can occur independently of the effect of stressors although it is uncommon.9 However it remains the case that stressful life events are a common causal antecedent to many depressive episodes a fact that has strong bearing on personal autonomy. Personal autonomy Through autonomous decisions individuals are well placed to act in accordance with deeply held values and goals that form a part of an overarching life plan.10 The information that is important for or material to such decisions is that with relevance for the person’s significant interests.11 To use an example from Pdgfra the informed consent model the small functional improvement that results from surgery for a minor fracture of the finger is likely to be material to a concert pianist but not to a professional boxer. Information about the relation between stressors and depressive disorder is Verlukast likely to be material to depressed people hence understanding it promotes the autonomy with which the person decides and acts in relation to a nerve-racking event. Appraisal theory which holds that unfavorable affect arises when important goals and interests are threatened supports this.12 Consider the despondency that often follows for example a broken engagement the loss of a job or failure in an examination. Depressive disorder although a pathological sadness can in many cases be thought of as an appraisal signifying loss disappointment and thwarted ambitions. If depressive disorder is viewed as a marker of a threat to interests there is good reason to see information pertaining to its trigger as material to the depressed person. Material facts in depressive disorder Three facets of the stressor-depression relation are strong candidates to comprise material information for depressed people. Firstly it is likely to be pertinent that stressors can bring around the disorder. If data from the general population can be used as a guide around a third of people with depressive disorder may fail to recognise this fact.13 Just as most would agree that people with asthma ought to be apprised of the deleterious effects of cigarette smoke so too should people with depression know of the aetiological role of stressors. This information affords a further option for dealing with the illness. Secondly it is important for depressed people to appreciate how nerve-racking events precipitate depressive disorder. Evidence supports a pivotal role for biases that favour the processing of negative information.14 These biases lead to unrealistic pessimism about the outcome of stressful events as well as excessive self attribution of their cause. In depressive disorder false negative thoughts are commonly taken at face value and guideline Verlukast the person’s subsequent behaviour. Given that such behaviour is mostly self defeating and that a more accurate way of dealing with negative thoughts can be learnt insight into the action of unfavorable biases is also likely to be material to the depressed person. Of course some circumstances are so grievous that a depressed response can seem warranted. The concept of “depressive.