At the same time, there is evidence that certain experiences can also predict whether someone will suffer from a significant depressive disorder in his life. These experiences include a history of child maltreatment, including emotional abuse, physical abuse, sexual abuse and profound neglect.[*] There is also evidence that mothers who suffer from untreated depression increase the risk that their children will suffer from depression - above and beyond the genetic risk that is transmitted to them.

Hence, it seems reasonable to speculate that with depression, as with most other medical conditions, genes and environment interact in the development of the illness.

Family History of Depression

I find that inquiring about family history of mental illness, including depressive disorders, often helps patients understand that genetics may play a key role in the manifestation of their illness. Furthermore, a family history of completed suicide may indicate how severe the depressive disorders are that run in the family as well as predict, to some degree, how likely it is that an individual might commit suicide.

Depression and the Role of Formative Experiences

Psychiatrists often spend a fair amount of time in their initial assessment trying to understand what the individual's cumulative emotional experience of childhood was like. The socio-developmental history often provides key information that may pertain to the development of a depressive disorder. Hence, psychiatrists will often inquire about:

1. The individual's memory of the overall emotional quality of his childhood (e.g. happy versus unhappy versus mixed)
2. The individual's basic temperament, including "affective" or mood temperament (e.g. shy/sensitive/anxious versus easy-going/relaxed versus difficult) and how these temperamental traits impacted the relationship between the individual and his family
3. Birth order
4. The family's emotional well-being at the time of the individual's birth
5. The emotional health of the individual's parents' relationship
6. Whether either or both parents had significant depression during the individual's childhood and what that was like for the individual and the family as a whole
7. What the individual's relationship with each parent was like, generally
8. What the individual's relationships with siblings were like
9. Emotional safety in the home (e.g. Was the home environment warm, loving and safe? Or unpredictable, tense, and volatile?)
10. How the individual was treated at various times of his childhood (e.g. Was the child loved? Was he shown warmth and affection? Was he respected and understood? Or, was he resented? Treated with scorn? Withheld affection? Punished frequently or indiscriminately?)
11. History of emotional, physical or sexual abuse
12. History of emotional neglect
13. Other traumatic experiences in childhood (e.g. death of a parent, illness /death of a sibling, frequent moves, being bullied, etc.)
14. School functioning and how the individual regarded school (enjoyed and performed well versus disliked and struggled with)
15. Presence of a specific learning disorder and/or Attention-Deficit/ Hyperactivity Disorder
16. The transition to adolescence and what that was like for the individual, emotionally speaking
17. Risk-taking behavior in adolescence
18. Substance abuse in adolescence

I believe that it is critically important for psychiatrists to understand what the predominant mood states were for the individual when he was a child. Were the mood states predominantly negative (sad, depressed, angry, scared) or predominantly positive (content, happy), for example? It seems reasonable to speculate that the ratio of negative mood states to positive mood states in childhood has something to do with the modulation of expression of depressive disorders later in life and that certain experiences that harken back to childhood may serve as psychological triggers for depression later in life.

Suicide Risk Assessment in Depression

In their assessment of a depressive disorder, psychiatrists are taught to invariably conduct a suicide risk assessment. It's always critically important to gauge an individual's current risk for suicide, as depression is thought to be one of the most important risk factor for suicide. If an individual expresses suicidal thoughts or feelings upon being queried, or spontaneously, a psychiatrist will inquire about:

1. How often he has those feelings or thoughts
2. How intense the thoughts/feelings are
3. How long they last when they come on (are they fleeting, do they last for a few hours or are they unremitting?)
4. Whether it ever gets to a point where the individual is ready to take action or feels an urge to end his life
5. Whether he has a plan in mind and what that plan is
6. Whether he has access to lethal means (such as a firearm, noose, or large quantity of medications)
7. Whether he is currently using or abusing alcohol and/or other substances
8. Whether there is significant agitation (an uncomfortable sense of energy) or anxiety (e.g. panic attacks) that co-occurs with the mood state
9. Whether, when the individual is not in an episode of serious depression, he has chronic thoughts of suicide
10. Whether he has made any previous attempts and what the nature of those attempts were
11. If he has written a note
12. If he has started to say goodbye to friends and family
13. If he feels a sense of relief or calm, having decided to soon kill himself
14. If he has people/pets in his life he is responsible for
15. Whether there are psychotic symptoms that make suicidal thoughts or impulses more intense (e.g. a voice telling the person to kill himself, extreme paranoia, or delusional guilt)

Psychiatrists will also often inquire about previous suicide attempts the individual may have made, because that information may have some value in predicting the likelihood that the individual will make another suicide attempt. This information can also reveal just how severe the individual's prior episodes of depression were, if, in fact, the suicide attempts were made in the context of depression. (Some individuals who are highly impulsive and have trouble with affect regulation do not necessarily need to experience a serious episode of depression in order to make a lethal suicide attempt. At the same time, anxiety states such as severe panic attacks can also increase the likelihood of a suicide attempt.)

Response to Previous Anti-Depressant Medication Trials

Another important area to cover in the psychiatric assessment of a depressive disorder is whether the individual has been on anti-depressant and/or other psychotropic medications before. I ask individuals to list all the medications they have taken for regulation of mood and anxiety. I then list for them the most common medications used to treat mood and anxiety disorders and ask them if they have ever been on those medications. Then, I try to construct a chronological list of all medications they have used for regulation of mood and anxiety and ask them to describe their response to each medication, how long they were on it, what side-effects they experienced, and why they were either taken off the medication or discontinued it. Sometimes, individuals have been tried on medication combinations and if this is the case, I ask how the combinations were arrived at (e.g. only partial efficacy of the first medication at maximal dose, leading to the addition of a second medication or use of a second medication to lessen the side-effects of the first, etc.) Sometimes, it becomes clear that a particular medication stood out as particularly intolerable or that another one worked best for someone. This information is useful because it will have some bearing on medication recommendations for the current episode of depression.