628523

research-article2016

CPXXXX10.1177/2167702616628523Beck and BredemeierA Unified Model of Depression

Theoretical/Methodological/Review Article

A Unified Model of Depression: Integrating

Clinical, Cognitive, Biological, and
Evolutionary Perspectives

Clinical Psychological Science

124
The Author(s) 2016
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DOI: 10.1177/2167702616628523
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Aaron T. Beck and Keith Bredemeier

Department of Psychiatry, University of Pennsylvania

Abstract
We propose that depression can be viewed as an adaptation to conserve energy after the perceived loss of an investment
in a vital resource such as a relationship, group identity, or personal asset. Tendencies to process information negatively
and experience strong biological reactions to stress (resulting from genes, trauma, or both) can lead to depressogenic
beliefs about the self, world, and future. These tendencies are mediated by alterations in brain areas/networks involved
in cognition and emotion regulation. Depressogenic beliefs predispose individuals to make cognitive appraisals that
amplify perceptions of loss, typically in response to stressors that impact available resources. Clinical features of severe
depression (e.g., anhedonia, anergia) result from these appraisals and biological reactions that they trigger (e.g.,
autonomic, immune, neurochemical). These symptoms were presumably adaptive in our evolutionary history, but are
maladaptive in contemporary times. Thus, severe depression can be considered an anachronistic manifestation of an
evolutionarily based program.
Keywords
depression, unified model, cognitive theory, biological, evolutionary
Received 12/10/15; Revision accepted 12/26/15

A substantial body of research has provided strong support for the cognitive model of depression (Clark & Beck,
1999). Nevertheless, key contributions from a number of
novel biological investigations since the most recent
update of this model (Beck, 2008) have helped expand
our understanding of the links between cognitive and
biological processes involved in depression and in turn
justified the proposal of a unified model of depression
within a cognitive framework. More important, there is a
need for a comprehensive theoretical model that brings
together relatively disparate literatures and accounts and
in doing so highlights emerging consistencies across
findings and perspectives while generating novel insights.
Such an endeavor should help promote integration and
collaboration within the field and in turn the development of more integrative approaches to clinical care
(both of which are still lacking).
A unified model of depression should fulfill a number
of requisites. First and foremost, it should integrate findings from various levels of analysis (e.g., genetic, psychological) into a coherent account. Second, it should fully

account for symptomatology, including those aspects of

depression that appear to violate the basic canons of
human nature (e.g., the sexual instinct and pleasure principle). Many theoretical models attempt to account for
only particular symptoms or cases and do not explicitly
address potential adaptive functions. Third, it should provide a framework to explain the natural history of depression: predisposition, precipitation, and recovery from the
disorder.1 For example, the model must be able to
account for documented variability in precipitating circumstances across individuals (e.g., cases of endogenous depression) and across time (e.g., sensitization to
stressors following initial recovery, also known as the
kindling effect).

Corresponding Author:
Aaron T. Beck, Department of Psychiatry, University of Pennsylvania,
3535 Market St., Room 2031, Philadelphia, PA 19104
E-mail: [email protected]

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Beck and Bredemeier

From Adaptation to Depression

Personality is organized to satisfy biologically determined
needs and to utilize vital human resources to help meet
those needs. These resources consist of close kinships,
peer groups, romantic partners, and identity groups,
which provide access to the necessities of life, including
nurturance, support, prospects for pair bonding, and elemental nutritional needs.2 Depression represents an
adaptation to the perceived loss of a vital resource investment that exceeds the individuals competencies and
capacities (e.g., resourcefulness, problem-solving, support) to mitigate the impact of the loss.
An important corollary of this adaptationist view of
depression, in contrast to the traditional disease model,
is that the symptoms are viewed on a continuum of
severity (see Nettle, 2004). In support of this view, most
evidence suggests that depression is dimensional (e.g.,
Beck, 1967; Haslam & Beck, 1994; Haslam, Holland, &
Kuppens, 2012; but for an alternative view, see Ruscio,
Brown, & Ruscio, 2009). Also, and particularly pertinent
to our model, evidence suggests that cognitive vulnerability to depression is dimensional (e.g., Gibb, Alloy,
Abramson, Beevers, & Miller, 2004). For practical purposes, we use the phrase severe depression in reference
to any case that is above the threshold of clinical significance, acknowledging that such thresholds are difficult
to determine (e.g., Wakefield & Schmitz, 2013; see
Horowitz & Wakefield, 2007). We also address the potential functions and adaptive value of milder (i.e., subclinical) symptoms, as these are key to an understanding
of when and how a given level of depression is dysfunctional or maladaptive (see Wakefield, 1999). To this end,
we begin with a brief review of the core aspects of the
cognitive model of depression, presented within an
adaptationist framework and in the context of our working model of personality (derived from research, theorizing, and clinical observations).

The structure of personality

Three systems of personalitycognitive, motivational/
behavioral, and affective (see Beck, 1996; Hilgard, 1980)
implement evolutionarily derived goals. We propose that
the cognitive system operates as a master program that
coordinates the other personality systems, as well as the
biological processes that support those systems (see also
Cantor, 1990; Denson, Spanovic, & Miller, 2009; Dweck &
Leggett, 1988; Lazarus, 1966, 1991; Ortony, Clore, & Collins, 1990; Weiner, 1985). This systems key functions are
to perceive, interpret, synthesize, and evaluate. Primal
needs are experienced subjectively as urges and cravings,
and these needs are met through the use of behavioral
strategies that increase the likelihood they will be

satisfied. Affective states provide positive and negative

reinforcement in support of the satisfaction of these basic
cravings and drives, as well as feedback on our progress
toward goals.
We propose that the beliefs most relevant to an individuals well-being involve domains of vital resources
(interpersonal relations and internal assets) and expectations of success or failure exploiting these resources. For
additional details about our conceptualization of the cognitive system and the general cognitive model (not specific to depression), please see Beck and Haigh (2014).
The affective and motivational/behavioral systems have
been described elsewhere (e.g., Beck, 1996; Ortony
etal., 1990; Weiner, 1985).

The cognitive triad

Beliefs are embedded in schemas. The cognitive triad
(Beck, 1967) consists of three schemas that simultaneously operate to determine the meaning/value of life
events (i.e., make appraisals) and generate appropriate
responses. These include the self-image (lovable vs.
unlovable), image of the world (friendly vs. unfriendly,
accepting vs. rejecting), and expectations of the future
(hopeful vs. hopeless).
Given the inherent constraints on how much information we can process at once, how we prioritize this information has important implications for our perceptions
and beliefs (and in turn, our well-being). When not
depressed, individuals generally show a positive bias in
attending to and recalling data from the flow of constant
information they receive from external and internal stimuli (e.g., Pool, Brosch, Delplanque, & Sander, in press;
Walker, Skowronski, & Thompson, 2003). This positive
bias has several adaptive consequences. For example, if
one overestimates the probability of a successful outcome from an endeavor, one may try harder and thereby
increase the probability of a positive result. Conversely,
beliefs and perceptions that produce mild sadness or
frustration can also be adaptive insofar as they motivate
an individual to take stock after a devaluing experience,
assess his or her role evenhandedly, and then problemsolve, withdraw, or adopt a new strategy (e.g., Alloy &
Abramson, 1979; Storbeck & Clore, 2005). We revisit and
further discuss this progression later, after detailing the
predisposition to and precipitation of severe depression
within the unified model.
Self-image and self-esteem. Individuals views of them
selves are represented in their self-image. The image is
colored by evaluative processing, generally referred to as
self-esteem. Horney (1937) first described the despised
self-image and idealized image. The idealized image is an
exaggerated form observed in manic states (accompanied

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A Unified Model of Depression

by extreme positive beliefs, such as I am superior),

whereas the despised image is seen in severe depression.
Although an individuals self-image is relatively stable, the
evaluative component may fluctuate, depending on his or
her life experiences. These evaluations are tied to the
pleasure/pain system so that losses or gains may stimulate
pleasant and unpleasant emotions.
Although self-evaluations may include a pejorative
element, the kind of harsh self-criticism observed in perfectionistic or severely depressed individuals emanates
from the imperative system. Notably, these injunctions
and prohibitions can be useful in everyday life, as can the
self-criticism that they may lead to. Like criticism from
others, self-criticism fosters learning that can guide future
behavior to head off unfavorable outcomes or to overcome inertia standing in the way of doing what is right.
For example, if an individual is caught cheating on an
exam, he or she is subjected to external criticism like
you are a cheat (actually an overgeneralization) and
incorporates this experience into memory. Thinking of
the experience elicits (emotional) pain, which motivates
him or her not to cheat in the future. The individual may
help to anchor this by thinking I am stupid to take a
chance like that. Notably, the extent to which the individual is personally invested in a particular life goal or
situation (e.g., a job) determines the extent to which perceived success or failure in that domain influences
self-esteem.
In severe depression, self-criticism tends to be magnified and inappropriate (and thus often becomes maladaptive). These self-criticisms are actually self-devaluations
(e.g., you are stupid, you are dumb, you are useless), and
begin to dominate consciousness in the form of ruminations about past mistakes and excessive/inappropriate
guilt. They become generalized to a negative self-concept
(e.g., viewing oneself as lazy, weak, or a burden), and
ultimately individuals may come to believe that their life
has no worth at all because they are also suffering. They
see that life itself has only a negative value (for themselves and others)therefore, the logical thing to do (in
their minds) is to get rid of this useless object (suicide; see
Bi etal., 2012; Joiner, Horn, Hagan, & Silva, in press; see
also Wenzel, Brown, & Beck, 2009, for details about the
cognitive model of suicidal acts).
Expectations for others and the future.Individuals
views of other people have important implications for
how they relate to others. These views also have an evaluative component, helping to differentiate kin from nonkin. However, more generalized views of groups and
people in general are also maintained, which has functional value (e.g., fostering expectations when encountering strangers). These generalized views of others
interact with the self-image to create expectations for

both the present and the future. Thus, strong negative

views of the self or others, but particularly their combination, lead to the high expectations for negative outcomes
and low expectations for positive outcomes seen in
severe depression. In turn, the depressed individual
begins to divest from previously valued interests and
attachments.
In the next section, we discuss in detail key factors
and processes that can lead to these extreme negative
evaluations of the self, others, and the future and, thus,
predispose individuals to experience severe depression.
Given the ambitiousness of this undertaking and the
scope of our article, we focus on general conclusions that
have emerged from various literatures, and refer readers
to key studies/reviews detailing the methodologies and
findings from those literatures. For a comprehensive
review of the depression literature, please see Gotlib and
Hammen (2014).

Predisposition
Most individuals by and large adapt reasonably well to life
stressors.3 They draw on their own resilience strategies
and problem-solving techniques and can lean on their
social support systems to soften the impact of adverse life
events. However, these strategies are undermined in individuals who have had early traumatic experiences, are
vulnerable because of genetic factors, or both. Consequently, they are at risk for severe depression and other
psychological disorders.4 A critical element in the development of vulnerability to depression is the formation of
depressogenic beliefs about the self, the world, and the
future (i.e., negative cognitive triad; Beck, 1967).

Distal vulnerability factors

There is growing evidence that traumatic experiences
can sensitize individuals to later interpersonal losses,
such that they increase risk for depression. An early
study, for example, showed that the loss of a parent in
childhood was associated with severe depression later in
life (Beck, 1963). In fact, adults who experienced early
parental loss may be sensitized to later experiences, such
that they require less stress to develop depression in
adulthood (see Slavich, Monroe, & Gotlib, 2011). Abuse
or adversity during childhood also appears to have a particularly formative effect (see, e.g., Gibb, Butler, & Beck,
2003; Hammen, Henry, & Daley, 2000). For example, the
impact of negative interactions with parents is illustrated
in elegantly designed observational studies demonstrating
that higher levels of negative emotional (e.g., aggressive)
expressions and behaviors by parents appear to prospectively predict depression in adolescence (e.g., Schwartz
etal., 2012; Schwartz etal., 2014).

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Beck and Bredemeier

4
Beyond their influence on cognitive development
(e.g., information processing, belief formation; both discussed more later), there is evidence that these sorts of
formative early experiences may disrupt neural development. For example, early life adversity has been linked
with reduced volume of the hippocampus (Rao et al.,
2010), a brain structure that plays a critical role in learning and memory formation (see Squire, 1992) and is
implicated in the neuropathology of depression (see
Campbell & MacQueen, 2004). It is important to note that
this reduction predicts later symptoms of depression
(Rao etal., 2010), and has also been observed in adults
who experienced emotional neglect during childhood
but have not (yet) suffered from severe depression (Frodl,
Reinhold, Koutsouleris, Reiser, & Meisenzahl, 2010).
It is clear, however, that not everyone who experiences adversity in childhood later becomes severely
depressed. One clue to this puzzle came from the landmark finding by Caspi and colleagues (2003) suggesting
that individuals possessing either one or two copies of
the short genetic variant of the serotonin transporterlinked polymorphic region (5-HTTLPR) experience
higher levels of depression and suicidality following a life
stressor. Furthermore, those who experienced maltreatment in childhood and also carried the 5-HTTLPR short
variant were more likely to become depressed as adults.
This finding was replicated by Kendler, Kuhn, Vittum,
Prescott, and Riley (2005), who demonstrated increased
sensitivity to severe depression in these individuals. Since
then, a number of other studies examining this genetic
polymorphism have yielded consistent findings. In a
sample of adolescents and young adults, the interaction
of 5-HTTLPR genotypes and major interpersonal stress
predicted the onset of severe depression (Vrshek-Schallhorn etal., 2014). Yet another study showed that these
genotypes were associated with more negative appraisals
of stressful life events, which in turn predicted future
depressive symptoms (Conway etal., 2012). The moderating effect of this genetic polymorphism on the link
between stress and depression was confirmed in a recent
meta-analysis (Karg, Burmeister, Shedden, & Sen, 2011;
for a broader review of supporting evidence, see Caspi,
Hariri, Holmes, Uher, & Moffitt, 2010; but for an alternative view, see Risch etal., 2009).
It is important that vulnerability to depression is almost
certainly polygenic (see Flint & Kendler, 2014, for a
detailed discussion and review), and other candidate
polymorphisms have been identified that may play a role
as well. For example, several studies (e.g., Kaufman etal.,
2006; Kudinova, McGeary, Knopik, & Gibb, 2015) have
found that the association between 5-HTTLPR genotypes
and depression is moderated by variants of the brainderived neurotrophic factor (BDNF) gene (a key neurochemical in neural development and known resilience

factor). Of note, BDNF gene variants have also been

linked with structural and functional abnormalities in the
hippocampus (e.g., Egan etal., 2003). Furthermore, the
minor variant of the FKBP5 gene (which modulates glucocorticoid receptors) has been shown to interact with
adverse life events to predict the onset of severe depression (e.g., Zimmerman et al., 2011). Notably, this polymorphism also predicts symptom course and prognosis
(e.g., Binder etal., 2004; Lekman etal., 2008). Also, proinflammatory genetic polymorphisms have been shown
to predict depression following chronic interpersonal
(but not other) stress (e.g., Tartter, Hammen, Bower,
Brennan, & Cole, 2015; see Raison & Miller, 2013, for
broader evidence linking genes involved in immune
functioning with depression). Finally, in line with other
evidence for a parallel between physical and emotional
pain (e.g., Eisenberger & Lieberman, 2004), genes that
regulate endogenous opioid production have been found
to moderate depressive reactions to targeted rejection
(Slavich & Irwin, 2014).
Critics of candidate gene research (e.g., Duncan &
Keller, 2011) point out that the effects in these studies are
small (particularly in relation to heritability estimates)
and have proven difficult to replicate. Although the
importance of confirming positive findings in genomewide association studies (GWAS) has been argued, unfortunately few reliable and consistent findings have
emerged from research using that rigorous methodological approach (see Cohen-Woods, Craig, & McGuffin,
2003; Flint & Kendler, 2014). Notably, a large GWAS study
by the Psychiatric Genomics Consortium (Cai etal., 2015)
did identify several locations on the genome associated
with shared risk for various forms of psychopathology,
including severe depression. More recently, the CONVERGE Consortium (Musliner etal., 2015) identified and
replicated a genetic signal near the SIRT1 gene (which is
involved in mitochondrial biogenesis) associated with
melancholic depression. We believe that both candidate
gene and genome-wide methodologies have important
merits (as well as limitations) for exploring genetic predisposition to depression, and are encouraged by emerging efforts to combine them (e.g., developing polygenic
risk scores and examining their interaction with environmental risk factors; Musliner etal., 2015).
Although there is not yet a clear consensus about the
specific genes that predispose an individual to depression, it is firmly established that depression risk has a heritable component, based on both behavior genetic research
(e.g., family, twin studies; see Sullivan, Neale, & Kendler,
2000) and molecular work (e.g., genome-wide complex
trait analysis; Lubke etal., 2012) to date. However, there
is also evidence that genetic risk is not necessary for
an individual to become predisposed to depression
severe negative experiences such as parental loss may be

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A Unified Model of Depression

sufficient (see, e.g., Kendler etal., 2005; Kendler, Neale,

Kessler, Heath, & Eaves, 1992). Furthermore, it is important to note that genetic and environmental risk factors
are by no means independent of one anotherrather,
there is emerging recognition that they mutually influence
one another in important ways. For example, our personal experiences can alter the expression of relevant
genes (e.g., Klengel etal., 2013; see Nestler, 2014). Conversely, the occurrence of certain stressful life events associated with risk for depression has been shown to have a
heritable component (e.g., family conflict; see Kendler,
1998; Kendler & Baker, 2007).

Information processing biases

It is well established that depressed individuals selectively attend to negative information (Peckham, McHugh,
& Otto, 2010) and ignore positive information (Winer &
Salem, in press). In turn, depressed individuals have been
found to be more sensitive to negative feedback (e.g., as
evidence by enhanced error-related negativity in eventrelated potential studies; see Olvet & Hajcak, 2008), and
also show impaired reward learning (e.g., Kumar etal.,
2008). Furthermore, depressed individuals tend to more
readily remember negative information (Dalgleish &
Watts, 1990) and have difficulty recalling specific autobiographical memories (leading to overgeneralization;
see Williams etal., 2007). Notably, there is mounting evidence that these information processing biases are not
simply a by-product of depressed mood, but rather confer vulnerability to depression (e.g., Gibbs & Rude, 2004;
Gotlib & Krasnoperova, 1998; Wells & Beevers, 2010).
Such biases may (in part) reflect impaired executive control, mediated by dysfunction of the prefrontal cortex and
other regions within the brains executive network (e.g.,
Elliott, Rubinsztein, Sahakian, & Dolan, 2002; Murphy
et al., 1999; see Levin, Heller, Mohanty, Herrington, &
Miller, 2007). Ultimately, they may contribute to overinterpretation of events and negative evaluations of life
experiences (see Joormann & Gotlib, 2006; MacLeod &
Hagan, 1992; Minnen, Wessel, Verhaak, & Smeenk, 2005),
and in turn shape the individuals views and expectations
over time.
Biases in information processing appear to mediate
the effects of genetic and environmental risk factors.
Although the relationship between serotonergic functioning and depression is still not fully understood, mounting
evidence suggests that the 5-HTTLPR short variant is
directly associated with negative processing biases (e.g.,
Beevers, Gibb, McGeary, & Miller, 2007; Beevers, Scott,
McGeary, & McGeary, 2009; Hayden etal., 2008; see Canli
& Lesch, 2007; Pergamin-Hight, Bakermans-Kranenburg,
Van Ijzendoorn, & Bar-Haim, 2012).Similarly, childhood
trauma and abuse predict information processing biases

later in life (e.g., Gibb, Schofield, & Coles, 2009; Pine

etal., 2005).

Stress reactivity
Biological reactivity to stress also seems to play a critical
role in the pathway from genetic and cognitive predisposition to depression. Dysregulation of the hypothalamicpituitary-adrenal (HPA) axis is one of the most consistent
biological correlates of severe depression (see Pariante &
Lightman, 2008; Stetler & Miller, 2011) and may be linked
to serotonergic or noradrenergic dysfunction (given the
important role of these neurotransmitters in HPA activation/regulation; see Dinan, 1996; Tsigos & Chrousos,
2002). Also, numerous studies have found elevated levels
of cortisol in response to stress in depressed individuals
(e.g., Burke, Davis, Otte, & Mohr, 2005; Knorr, Vinberg,
Kessing, & Wetterslev, 2010; Stetler & Miller, 2011). Notably, cortisol reactivity has also been observed in healthy
individuals with the FKBP5 gene minor variant (e.g.,
Ising etal., 2008), carriers of the 5-HTTLPR short variant
(see Miller etal., 2013), and individuals who lost a parent
during childhood (e.g., Tyrka et al., 2008). Over time,
elevated cortisol can lead to neural atrophy (mediated by
glutamate, and particularly in the hippocampus;5 see
McEwen, 2003; Sapolsky, 2000) that could further exacerbate HPA dysregulation (as the hippocampus plays a key
role in HPA feedback inhibition; see Mahar, Bambico,
Mechawar, & Nobrega, 2014) and memory biases (e.g.,
Gerritsen etal., 2012; Young etal., 2012; see Gradin &
Pomi, 2008).
The amygdala, a brain region strongly implicated in
salience detection, emotional processing, and activation
of the HPA axis (Adolphs, 2010; Herman & Cullinan,
1997), seems to play an important role in this stress reactivity and its apparent link with information processing
(see also Disner, Beevers, Haigh, & Beck, 2011). The
extent to which the amygdala is activated by negative
stimuli is directly associated with 5-HTTLPR genotypes
(see Munaf, Brown, & Hariri, 2008), and carriers of the
short variant have been found to show elevated amygdala activation and cortisol responses when attempting
to repair their mood (Gotlib, Joormann, Minor, & Hallmayer, 2008). Likewise, enhanced amygdala reactivity is
associated with childhood maltreatment, independent of
psychiatric status (e.g., Van Harmelen et al., 2013).
In turn, amygdala activation predicts biased recall of
negative information in individuals with a history of
depression (e.g., Ramel etal., 2007), as does functional
connectivity between the amygdala and hippocampus
(e.g., Hamilton & Gotlib, 2008). In short, this biological
reactivity to environmental input/stress may foster greater
affective instability (see, e.g., Thompson, Berenbaum, &
Bredemeier, 2011) and in turn strengthen learning.

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Beck and Bredemeier

Belief formation
In simplified terms, the developmental sequence to predisposition follows the genetic or environmental risk to
negative memories of devaluation as well as negative
evaluations of the self and future. Resulting negative
views coalesce into the negative cognitive triad.
Support for this formulation is provided by the large
number of publications detailing the role of negative selfesteem as a predictor of future depression (see Sowislo &
Orth, 2013), and more recent evidence that the tendency
to experience a decline in self-esteem (shown using ecological momentary assessment) in response to negative
events does as well (e.g., Clasen, Fisher, & Beevers, 2015).
Research using the Dysfunctional Attitude Scale (DAS;
Weissman & Beck, 1978) lends further support to this
model. This scale includes items such as if I dont do
well all the time, it means I am a failure. Numerous studies have shown that these attitudes moderate the impact
of stressful life events on depression (e.g., Abela & Skitch,
2007; Abela & Sullivan, 2003; Hankin, Abramson, Miller,
& Haeffel, 2004; Lewinsohn, Joiner, & Rohde, 2001).
These negative attitudes and beliefs seem to result
inimportant and predictable learned patterns of appraising
life experiences/events. For example, using the Attributional Style Questionnaire, Alloy, Abramson, and colleag
ues(e.g., Alloy, Abramson, & Francis, 1999; Alloy, Abramson,
Whitehouse, etal., 1999) have demonstrated that depression-prone people have a tendency to view negative events
as caused by themselves and anticipate enduring negative
consequences. This attributional style prospectively
predicts depressive symptoms (e.g., Hankin et al., 2004;
Nolen-Hoeksema, Girguis, & Seligman, 1986) and has been
linked with maltreatment in childhood (e.g., Gibb, Alloy,
Abramson, & Marx, 2003). In turn, these individuals become
more pessimistic about the future (e.g., Alloy & Ahrens,
1987; Metalsky & Joiner, 1992).
Our general model of depression proneness or predisposition is portrayed in Figure 1. As shown in this figure,
we propose that genetic and experiential risk factors contribute to the development of information processing
biases and biological reactivity to stress. Over time, these
processes can lead to the development of depressogenic
beliefs (i.e., negative views of the self, world, and future),
which in turn further exacerbate processing biases and
stress reactivity. Early negative experiences are also
hypothesized to contribute directly to depressogenic
belief formation.

Pinpointing person-specific
vulnerabilities

have specific vulnerabilities that are triggered by specific

types of stressors/events (e.g., Hammen & GoodmanBrown, 1990; Robins, 1990; Segal, Shaw, Vella, & Katz,
1992). For example, there is evidence that individuals
who place greater value on independence or autonomy
are relatively more sensitive to events that impinge on or
undermine their sense of achievement, mastery, and control (e.g., Clark, Steer, Haslam, Beck, & Brown, 1997;
Hammen, Ellicott, Gitlin, & Jamison, 1989; see Beck,
1982; but for an alternative view, see Clark, Beck, &
Brown, 1992). Conversely, those with higher levels of
dependency (i.e., sociotropy) seem to be more sensitive to interpersonal stress, particular events that involve
feeling rejected or abandoned. These personality factors
may also influence symptom expressionfor example,
dependent individuals may be more likely to cry, whereas
autonomous individuals may be more likely to withdrawal (see, e.g., Clark etal., 1997).
Some of these vulnerabilities are salient during particular development periods and are represented by conditional beliefs. For example, adolescents tend to develop
acute sensitivity to criticism and rejection by other people (Chango, McElhaney, Allen, Schad, & Marston, 2012).
In turn, they may be prone to develop beliefs such as if
somebody rejects me, it means I am undesirable.
Individuals often attempt to create circumstances in
their lives that will counteract or compensate for these
specific vulnerabilities. An individual, for example, might
develop skills as an entertainer as a way of connecting to
compensate for inner loneliness or fear of group rejection.
When such an individual fails to entertain a relevant
group, the perceived bond with other people is broken,
increasing susceptibility to depression. It is important that
such compensatory behaviors may serve to reinforce key
beliefs. For example, an individual might come to believe
that he or she will be liked or accepted by others only if
he or she entertains them. Also, compensatory behaviors
such as these can elicit negative reactions from others,
presenting yet more stress to the individual (see Hammen,
2006; Lewinsohn, Mischel, Chaplin, & Barton, 1980).

Precipitation
Predisposition is not sufficient to cause depression
rather, something must trigger the onset of symptoms.
We propose that the critical element in the precipitation
of depression is the perceived loss of the investment in a
vital resource.

Stress as a common precursor

In addition to the general vulnerabilities we have

described earlier, depression-prone individuals often

In line with the traditional diathesis-stress model, various

adverse life experiences predict the onset of severe
depression (see Hammen, 2005; Kendler, Karkowski, &

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A Unified Model of Depression

Early Experiences
/Trauma

Information Processing
Biases

e.g., Parental Loss,

Maltreatment

e.g., Attention, Memory,

Inferential/Attributional

Depressogenic Beliefs
i.e., the Negative Cognitive Triad

Genetic Risk
e.g., 5-HTTLPR Short
Variant, FKBP5 Minor
Variant

Biological Stress
Reactivity
e.g., Amygdala,
HPA Axis, Cortisol

Fig. 1. Predisposition to depression. According to our unified model, genetic risk and early experiences/trauma both contribute to the development of information processing biases and biological reactivity to stress. Over time, these tendencies
can lead to the development of the negative cognitive triad (i.e., depressogenic beliefs about the self, world, and future).
In turn, the formation and activation of these beliefs further exacerbate cognitive biases and stress reactivity. Early experiences/trauma are also considered to play a direct role in the formation of depressogenic beliefs.

Prescott, 1999). Rejection by a loved one, social exclusion

or degradation, loss of a child, and loss of productivity
are among the most potent precipitants of depression
(see Kendler, Hettema, Butera, Gardner, & Prescott, 2003;
Slavich, Thornton, Torres, Monroe, & Gotlib, 2009). The
common thread among these stressors is that they appear
to negatively impact key evolutionary goals such as having close interpersonal relationships, reproductive success, acceptance by the identity group, and effective
internal resources. However, the precipitant does not
need to be a discrete eventchronic stressors (e.g., marital discord, financial difficulties) can lead to depression
as well (Hammen, 2005). The body responds to stressors
through activation of the HPA axis and the release of
cortisol (Selye, 1973), both of which are typically amplified in those prone to depression (as discussed earlier).
The precipitating stressor impacts one or more vital
resources, depending on the stage of life and the unique
vulnerabilities of the individual. In infancy, the loss of
nurturance from a parental figure can lead to anaclitic
depression (Spitz & Wolf, 1946). Adolescents seek acceptance and are particularly sensitive to exclusion by their
peer group. For example, in a longitudinal study of lateadolescent women, nonsevere interpersonal stressors
were nearly two times more likely to be followed by
severe depressive episodes than noninterpersonal ones
(Stroud, Davila, Hammen, & Vrshek-Schallhorn, 2011).
Adults, on the other hand, are especially likely to react to
rejection by an intimate partner or exclusion by the larger
community (e.g., Slavich et al., 2009). Finally, we have
observed that older adults who have been productive
most of their lives may slip into severe depression after
they recognize that they have lost some competencies or
experienced failure in their occupations.
Of note, recurrent bipolar and endogenous depressions can occur without obvious precipitating events or

stressors. Severe depressive episodes, whether or not

they occur in reaction to external events/circumstances,
are characterized by a catastrophic loss of self-esteem
and dominant negative bias in perceiving ongoing
experiences and anticipating the future. Nevertheless,
depressed individuals who experience a severe life event
prior to the onset of their symptoms have been found to
exhibit greater variability in negative attitudes over the
course of the episode than depressed individuals without
a severe precipitating event (Monroe, Slavich, Torres, &
Gotlib, 2007).

The role of appraisals

Of course, adverse events/stressors do not always lead to
depression. Everyone experiences painful events that
lead to sadness or anger, but we propose that these do
not culminate in full-blown depression unless there is a
perceived loss of what they believe to be a vital investment. Furthermore, it is critical that this loss be perceived
as beyond the individuals control (Brown & Siegel,
1988), and thus irreversible. In essence, the impact of a
depressogenic event depends on its personal meaning.
In turn, an events meaning is contingent on the value
that the individual places on the investment, reflected in
the perceived importance of the resource in question.
The magnitude of perceived loss is proportional to
individuals degree of investment. When individuals allocate their cravings, expectancies, energy, and even wellbeing to their investment, the loss will be intense. For
example, an individual who invests heavily in a romantic
relationship would be particularly vulnerable to depression if that relationship ends. When the individual utilizes
this investment to compensate for beliefs of undesirability, inferiority, or inadequacy, his or her loss is further
compounded.

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Beck and Bredemeier

8
Negative thinking about and interpretations of experiences can be considered proximal cognitive causes of
depression (Hammen & Watkins, 2008). In line with this
formulation, it has been demonstrated that cortisol
changes in response to stressors are closely tied to cognitive appraisals of those events (e.g., Gaab, Rohleder,
Nater, & Ehlert, 2005; see Denson et al., 2009, for a
review).

The role of schemas

The link between stress and severe depression appears
to change over multiple episodes, such that an individuals threshold of stress necessary to precipitate onset
may decrease over recurrences (referred to as the kindling effect; e.g., Post, 1992; Stroud et al., 2011; see
Monroe & Harkness, 2005). And as previously mentioned,
depressive episodes can certainly occur without any
apparent precipitant, and yet are still characterized by
profound depressive thinking. Schema theory can help to
explain both of these phenomena.
The predispositional schemas (negative cognitive
triad) become activated as a result of a stressor that is
congruent with the schematic belief, which in turn influences subsequent information processing. The levels of
depression (mild, moderate, or severe) depend on the
degree of activation. The content of negative beliefs is
graded and fluctuates with the degree of activation (e.g.,
I am clumsy and inept vs. I am a total loser). In turn,
this activation and subsequent biasing of information
processing and interpretations/appraisals further reinforces and strengthens the schema, causing it to become
increasingly more dominant, essentially preempting other
more adaptive schemas. Through this continuous cycle
of reinforcement, these schemas become denser, more
robust, and less permeable. At a biological level, this is
likely reflected in the strengthening of relevant synaptic
connections (and, in turn, neural networks). These cognitive and biological changes reflect learning processes that
promote adaptation, all things equal. Yet in recurrent
depressions, the schemas become consolidated through
this cycle of increasingly negative perceptions and interpretations. Under these conditions, negative schemas
begin to have a continuous low level of activation even
during asymptomatic periods, and in turn are more easily
raised to maximum activation (the kindling effect). Similarly, these schemas become frozen and are therefore
relatively impermeable to positive life events. In endogenous depression, these schemas are consolidated to a
degree that very minimal (if any) additional activation is
required. For further elaboration, see Beck and Haigh
(2014).
Support for this formulation comes from work by
Lewinsohn, Allen, Seeley, and Gotlib (1999), which

showed that stressful events are more predictive of initial

onset of severe depression, whereas depressogenic attitudes (measured by the DAS) are more predictive of
recurrence. Furthermore, research suggests that experiencing depression leads to greater cognitive reactivity
(e.g., depressogenic attitudes when in a sad mood),
which in turn predicts risk of recurrence (Lau, Segal, &
Williams, 2004; Teasdale, 1988). Finally, experiencing
severe depression leads to a decreased sense of mastery
over time (Nolen-Hoeksema, Larson, & Grayson, 1999).
We propose that these findings reflect the consolidation
of depressogenic schemas. Along with the enhanced
reactivity and diminished cognitive control that may
result from neural atrophy (discussed earlier), this consolidation increases risk.
But why does the perceived loss of a vital investment
produce such a profound effect? We suggest that the
internal representation of the self and the vital resources
in question constitute a prominent part of the cognitive
organization (i.e., core beliefs) and are embedded in
schemas that include various beliefs and the meaning
associated with both the self and the resource. More specifically, internal representations of the self and these
vital resources overlap and become assimilated into the
self-schema. Thus, the disruption of this integration following precipitating events leads to the profound sense
of loss. For example, the self-image of those who invest
heavily in romantic relationships may come to center on
feeling lovable. As a result, relationship difficulties (e.g.,
a breakup) may make them feel not only unlovable, but
worthless and hopeless.

The Evolutionary-Based Depression

Program
Negative thoughts/beliefs can directly account for many
cardinal depressive symptoms (e.g., sadness, self-criticism,
difficulty sleeping, suicidal behavior; see Beck, 1976;
Lewinsohn, Hoberman, & Rosenbaum, 1988). They reflect
extreme deactivations of positive schemas (resulting in
decreased investments) as well as activations of negative schemas (promoting withdrawal). The apparent dysfunctionality of severe depression, represented by
symptoms such as profound anergia and anorexia, is best
understood by carefully considering the potential evolutionary value of such symptoms. In doing so, we expand
on a previous cognitive-evolutionary formulation (Beck,
1993), incorporating more clinical features as well as new
scientific findings (for discussions of other evolutionary
accounts, see Durisko, Mulsant, & Andrews, 2015; Rottenberg, 2014). Initial clues about the evolutionary origins and functions of depression come from work
examining depression-like behaviors/syndromes in other
species.

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A Unified Model of Depression

Nonhuman animal studies

Making extrapolations from the present to the past (what
may have happened) and back to the present again
(what could be happening) is a risky undertaking,
beset with anthropomorphism, zoomorphism, and circular reasoning. Still, animal models can provide an interesting heuristic approach to the task of unraveling the
mystery of depression.
Animal observations and experiments suggest that,
following social deprivation, primates manifest behavioral characteristics that resemble human depression
(McKinney, Suomi, & Harlow, 1971), such as crying,
decreased activity, and social interaction, decreased
appetite, and sleep disturbances. It has been speculated
that a key function of this deprivation depression is to
attract the attention of significant others. Other experimental work with primates has shown a hypersensitivity
to the loss of an intimate relationship, as well as losses in
competitive struggles that result in a lowering of group
status (defeat depression). By adopting a submissive
role, the individual no longer invites attacks from competitors (Gilbert, 1989; Price & Sloman, 1987).
Of note, depressive reactions have been observed in
nonprimate species as well (see McKinney & Bunney,
1969). For example, rats develop a depression-like state
following maternal separation (Hall, 1998), characterized
by a significant decline in motor activity. Similarly, depression can occur in dogs when separated from their owner
(Aisa, Tordera, Lasheras, Del Rio, & Ramirez, 2008). And
it has been shown that these same species can exhibit
helplessness in response to uncontrollable stressors
(e.g., inescapable shock; Seligman & Maier, 1967), which
extinguishes instrumental learning as well as interest in
food, sex, and play.
These findings reinforce the idea that depression may
have evolutionary origins (derived through nature selection because of its adaptive value), and point to some
potential functions it may serve (e.g., protection). Even
more interesting, other species seem to exhibit depressive reactions in response to the same types of events
that precipitate depression in humans (e.g., loss of a
caregiver or group status). Finally, these reactions seem
to consistently involve a profound damping down of
activities.

Conservation of energy
As noted earlier, vital resources such as social relationships
play an important role in helping us meet evolutionarily
derived goals/needs. Thus, following the perceived loss of
a vital investment, we are naturally drawn to compensate
for this loss by limiting all activity not necessary for survival. To implement this conservation strategy/program,

sexual drive, hunger, and parenting are largely extinguished. Under the condition of an expectation of exhaustion of residual energy, an enforced conservation of energy
would permit the individual to survive until the circumstances become more favorable. Of note, similar energy
conservation strategies are observed in other species,
under certain environmental conditions (e.g., amphibians
in cold weather). In fact, the increased incidence of depressive symptoms/episodes during the fall and winter months
(see, e.g., Magnusson, 2000) could be considered in line
with this formulation (see also Davis & Levitan, 2005),6
perhaps suggesting an evolutionarily derived sensitivity of
the depression program to environmental cues signaling
scarcity of various sources of sustenance (e.g., reduced
sunlight). With the development of social behavior at a
later stage of evolution, other members of the social group
assumed a key role in promoting survival. Thus, the same
strategy that conserved energy during food scarcity was
later displaced onto the loss of human resources (see
also Allen & Badcock, 2003).
To the extent that objective circumstances warrant
energy conservation, such behavioral strategies can be
considered adaptive. Similarly, factors that predispose
individuals to depression (e.g., information processing
biases, stress reactivity) can be considered adaptive in
particular environmental situations (e.g., persistent danger or persecution). However, these symptoms and factors likely were more often warranted (and therefore
adaptive) in our evolutionary history than they are in the
contemporary context. Also, we propose that, like other
evolutionarily based programs derived through nature
selection (e.g., the fight-or flight response), the degree of
activation of the depression program varies (concomitant
with the extent of the perceived loss and resulting schema
activation), accounting for symptoms that range from
mild (i.e., dysphoria) to the most severe (i.e., melancholia). As previously noted, mild symptoms may generally
be adaptive even today, in that they can motivate us to
take stock after a devaluing experience (see, e.g., Alloy &
Abramson, 1979; Wakefield & Schmitz, 2013). Conversely,
in their most extreme forms, some symptoms inherently
undermine the individuals prospects for survival and
procreation (e.g., suicidal acts).
Support for the conservation of energy hypothesis
comes from the noted parallel between sickness behaviors of individuals experiencing infection and symptoms
of severe depression (see, e.g., Dantzer, OConnor,
Freund, Johnson, & Kelley, 2008; Durisko et al., 2015).
Evidence for the mobilization of the immune system in
depression is indicated by the presence of proinflammatory immune bodies (cytokines; see Dowlati etal., 2010;
Slavich & Irwin, 2014),7 as well as experimental research
showing that inducing inflammation in humans can cause
severe depressive symptoms (e.g., Capuron & Miller,

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Beck and Bredemeier

10
2004; Harrison etal., 2009). Recent findings suggest that
this immune activation may be driven by stress-induced
endogenous opioids (e.g., Prossin et al., in press). The
physiological components of both infection and depression can be viewed as consequences of the limitation of
the expenditure of energy. Because the immune response
to infections consumes an inordinate amount of energy,
the body is programmed to reduce energy output not
essential for immediate survival (see also Segerstrom,
2007). Thus, loss of appetite, loss of sexual drive, and
generalized fatigue tend to restrict energy-demanding
activities such as foraging for food and engaging in sex.
Activation of the parasympathetic nervous system (which
generally promotes rest and digest) may also play an
important mediating role in these symptoms/behaviors,
as evidenced by research showing that depression
is associated with respiratory sinus arrhythmia (e.g.,
Yaroslavsky, Rottenberg, & Kovacs, 2013), vagal tone
(e.g., Kogan, Gruber, Shallcross, Ford, & Mauss, 2013),
and other biomarkers of parasympathetic activation (see
Lin, Lin, Lin, & Huang, 2011). Finally, emerging evidence
shows that the serotonin system plays a key role in
energy regulation (see Andrews, Bharwani, Lee, Fox, &
Thomson, 2015), suggesting that serotonergic dysregulation may contribute as well.
Although others have highlighted that these sickness
behaviors promote energy conservation, we propose
that common cognitive and emotional symptoms of
depression can be conceptualized within this same functional framework. Perhaps most notably, depressed
mood (and the negative thoughts that accompany it)
promotes withdrawal from people and activities. Also,
the broad cognitive deficits (see McDermott & Ebmeier,
2009) and psychomotor retardation seen in severe
depression may be viewed as a consequence of energy
conservation mechanisms within the brain (typically a
large consumer of the bodys energy). In line with this
proposal, depressed individuals show decreased neural/
metabolic activity in several areas of thebrain (e.g., prefrontal regions; see Drevets, 2000; Mayberg, 1997). Furthermore, there is evidence that depressed individuals
often fail to deactivate the brains default-mode network (which includes the hippocampus) when asked to
perform a task (e.g., Sheline etal., 2009; see Hamilton,
Chen, & Gotlib, 2013), which may also have a net effect
of conserving energy. Diminished communicative behavior observed in depression (e.g., blunted affect; see
Berenbaum & Oltmanns, 1992; Rottenberg, Gross,
Wilhelm, Najmi, & Gotlib, 2002) might be seen as a strategy that prevents unnecessary energy expenditure as
well, in light of concomitant social withdrawal. Finally,
another key factor contributing to inactivity is diminished pleasure in previously valued goals and activities,
as evidenced by research showing muted responses to
pleasurable stimuli in depression (e.g., Pizzagalli etal.,

2009) as well as after experimentally induced inflammation (e.g., Eisenberger etal., 2010). Dopaminergic dysfunction is thought to play a key role in this phenomenon,
and perhaps cognitive and motor disturbances as well
(Nestler & Carlezon, 2006; Willner, 1995), which may be
a biological mechanism for discouraging appetitive
behavior (and thus energy consumption) during stress or
illness. Of note, loss of libido, decreased investment in
progeny, and withdrawal from close relationships (all
vital evolutionary demands) parallel the common precipitating factors of rejection by a lover, loss of an offspring, and public humiliation.
The initial cognitive evolutionary formulation (Beck,
1993) did not attempt to account for atypical symptoms
of depression, such as hypersomnia and increased appetite (American Psychiatric Association [APA], 2013). Nevertheless, if conceptualized as behavioral strategies to
replenish energy, these symptoms can be considered in
line with the broader function of energy conservation as
well. Specifically, sleeping more than usual undoubtedly
promotes energy restoration beyond mere inactivity, and
notably is common in response to infection. Similarly,
increased caloric intake should increase energy reserves,
overcoming the fact that some energy is used in the process of consumption (especially if minimal effort/energy
is required to obtain the food). It is interesting that
increased appetite is common in seasonal depression
(APA, 2013; Rosenthal etal., 1984), perhaps reflecting an
evolutionarily derived strategy to compensate for
decreased food availability during winter. Biologically,
some recent evidence suggests that the likelihood of
depression being manifest in traditional versus atypical
forms (e.g., decreased vs. increased sleep and appetite)
reflects the relative balance of the stress and immune
responses within an individual (e.g., Lamers etal., 2013),
but this requires further testing/replication. From a cognitive perspective, we hypothesize that atypical depressive
symptoms may be more common in the absence of
prominent hopelessness (leading to perceptions that current resource scarcity is temporary). We are not aware of
any research that has tested this directly. But notably, in
a recent, large-scale factor analytic study of clinical symptom ratings, hopelessness and atypical symptoms did
load on separate factors (Li etal., 2014). This prediction
is also consistent with lower levels of hopelessness
observed in seasonal depression (Michalak etal., 2002),
which is commonly characterized by certain atypical
symptoms (e.g., hypersomnia; APA, 2013).

The necessity of maintaining vigilance

Still, some symptoms of depression, including a few that
are more commonly seen in atypical presentations (e.g.,
psychomotor agitation), seem difficult to reconcile with
the conservation of energy hypothesis. Specifically, it

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A Unified Model of Depression

11

would appear that these symptoms deplete, rather than

conserve or restore, energy. To understand the function
of these symptoms and how they might fit within the
depression program, we argue that it is essential to consider the evolutionary significance of ongoing vigilance
for threat.
Even when energy conservation is a salient goal, monitoring the environment for potential danger remains crucial to survival. In fact, one could argue that vigilance is
even more important when energy is being conserved, as
inactivity/immobility would make one an easy prey. So, it
is understandable that depressed individuals would
exhibit vigilance (Lebano, 2015), as suggested by neuroimaging findings that reveal increased activity in some
brain regions involved in attention and vigilance (i.e.,
the salience network), such as the amygdala (discussed
earlier) and areas of the anterior cingulate cortex and
insula (see Drevets, 2000; Hamilton et al., 2013). This
vigilance, particularly in combination with a preexisting
tendency to attend to negative stimuli, should promote
the rapid detection of any dangers that arise. Consistent
with this account, it has been shown that attentional
biases in depression-prone individuals are accentuated
during negative mood states (e.g., McCabe, Gotlib, &
Martin, 2000), as is error monitoring (e.g., Olvet & Hajcak, 2008). We hypothesize that several common depressive symptoms (e.g., psychomotor agitation, difficulty
concentrating, insomnia) serve to promote this vigilance
(or, alternatively, are a consequence of it). The same may
be true for anxiety and irritability, which commonly cooccur with depression. Finally, social withdrawal and
inactivity could be seen as also serving this overarching
protective function (in addition to conserving energy), by
limiting numerous risks. Arguably, this is consonant with
the apparent functions of some depressive-like syndromes in other species (e.g., defeat depression).
The immune response may play a mediating role in
this vigilance as well, as evidenced by neuroimaging
studies examining the cognitive effects of induced
inflammation (see Miller, Maletic, & Raison, 2009), perhaps as an important evolutionary safeguard during
times of sickness. Also, inflammation further activates
the HPA axis (see Leonard, 2005). When considered
along with bidirectional links between negative thinking
and beliefs, one can see how the depression program
can become self-perpetuating (and even self-enhancing)
once activated.

From adaptation to depression,

revisited
The evolutionary-based depression program involves
coordinated activations and deactivations of the cognitive, affective, and motivational/behavioral systems of
personality. Negative life events do not inherently

activate this program, although they do routinely activate

parts of it (e.g., sadness, elimination of the positivity bias)
that are functionally relevant to the situation at hand
(e.g., promoting accurate memory; Storbeck & Clore,
2005). Rather, we propose that such events do not fully
activate the depression program unless there is a perceived loss of a vital investment. Even when this occurs,
the degree of activation varies (and in turn, so does the
severity of negative thinking, biased information processing, HPA/immune activation, and resulting symptoms)
based on the magnitude of the perceived loss. At lower
levels of activation, the dampening of energy consumption may be relatively mild, and can even stimulate or
help foster adaptive responses (e.g., problem-solving;
see Andrews & Thomson, 2009). However, at the highest
levels, the pull to conserve energy overcomes the individual (based on our evolutionary heritage, given the
adaptive value this would have had for our ancestors).
This shift in balance might explain why depressive symptomatology can appear categorical in certain respects
(e.g., Ruscio etal., 2009), as there is often marked behavioral changes when this occurs (e.g., from support seeking to withdrawal). From a cognitive perspective, this
shift would likely occur when the individual develops
perceptions of helplessness or hopelessness. The point at
which these symptoms become maladaptive (and thus
clinically significant) is subject to debate, but likely varies across individuals (based on their unique life circumstances) and depends a great deal on their duration/
frequency. Nevertheless, we are hopeful that our model
can inform diagnostic decision making, based on our proposal that the energy conservation functions of depression
are unlikely to be adaptive in contemporary timesthus,
significant impairment should be more likely when they
predominate. Furthermore, it is important to consider the
accuracy of the individuals perceptions about the precipitating loss, as marked distortions in these perceptions are
more likely to promote maladaptive responses.
Predisposition plays an important role in this progression. Specifically, individuals who are predisposed to
depression exhibit greater sensitivity to stress (see, e.g.,
Hammen et al., 2000; Kendler, Thornton, & Gardner,
2001), and in turn have lower thresholds along this continuum (based on exaggeration of loss due to their beliefs
about the importance of certain resources or their ability
to cope). Again, such heightened sensitivity can have
adaptive value in certain circumstances. Conversely,
those with key resilience factors (discussed briefly later)
would exhibit the opposite tendency. That is, resilient
individuals are more capable of responding adaptively
when the depression program is activated, and thus less
likely to progress to severe depression. Furthermore, if
these individuals ever do become severely depressed
(e.g., as the result of a severe stressor), they would be
better able to reverse the program. In some respects,

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Beck and Bredemeier

12
clinical decision making (about diagnosis and treatment)
hinges on determining who is at risk and then how to
intervene to reduce risk and promote resilience.
The proposed links between precipitating factors and
symptoms of depression described earlier are portrayed
in Figure 2. As shown in this figure, depressogenic beliefs
interact with the precipitating stressor(s) to generate negative cognitive appraisals. It is important that both stress
and predisposing beliefs may not be necessary to precipitate such appraisals, and yet can be sufficient. When
there is a perceived loss of a vital investment, cognitive,
emotional, and biological processes are initiated in service of energy conservation. In this sense, the conservation of energy is under cognitive control, and will in turn
be abandoned when the cognitive appraisal changes
from a worldview of scarcity to one of availability of vital
resources. In line with this idea, cognitive appraisals also
play a critical and direct role in mediating the effect of
stress on immune functioning (see Denson etal., 2009).
Controlled by areas of the brain that evolved relatively
later (e.g., prefrontal cortex; see Ochsner & Gross, 2005),
this capacity for cognitive flexibility is generally quite
adaptive for responding to complex or novel situational
demands. And yet, the presence of depressogenic beliefs
can undermine the utilization of this capacity (and more
broadly, strategies for terminating the program). In this
sense, the capacity to develop such beliefs (which may
be unique to humans) creates the potential for chronic
difficulties that can persist even after a stressful situation
has resolved (see Sapolsky, 2004), and in turn bouts of
depression that are prolonged or endogenous. Furthermore, these beliefs (and the schemas in which they are
embedded) are reinforced/strengthened by negative
appraisals, which can promote cognitive and behavioral
rigidity (e.g., reflected in diminished activity within the
brains executive network; see Hamilton etal., 2013). We
return to these topics later when (briefly) discussing ways
to alleviate depression.

Summary and Integration

There is a continuity of cognitive structure and function
across all domains pertinent to depression. Starting at the
earliest stage of cognition, negative perceptions and
appraisals lead in sequence to negative thoughts and
beliefs. The beliefs, embedded in schemas, further influence information processing and interpretations in the
predisposition to and precipitation of severe depression.
There is also continuity from the evolutionary prototype to the current experience of depression. From both
perspectives, the appraisal of the loss of a vital investment/resource leads to a profound damping down of
energy consuming functions. In this sense, severe depression can be considered an extension of normal/adaptive

functions, which fully manifests when it is perceived that

the loss of the resource exceeds capacities/competencies, and typically becomes maladaptive only when the
perceptions driving them are distorted.
Biological and evolutionary approaches to depression
have been investigated utilizing genotyping, neuroimaging, hormone assays, examinations of immune and autonomic responses, and nonhuman animal observations
and experiments. Investigations at each of these levels
have contributed greatly to our understanding of depression, and in turn, the proposed unified model.
Genetic level: Genetic polymorphisms associated with
risk (e.g., 5-HTTLPR, FKBP5) and resilience (e.g.,
BDNF) appear to contribute to cognitive biases or
reactivity to stress (e.g., Miller etal., 2013; PergaminHight etal., 2012), which promote the development of
negative beliefs. These beliefs (and the schemas in
which they are embedded) constitute predisposition
to depression.
Neuroanatomical level: Links between genetic and
environmental risk, cognitive biases, and stress reactivity are mediated by structural and functional alterations in several brain regions/networks, most notably
the amygdala (salience network), hippocampus
(default-mode network), and prefrontal cortex (executive network) (Beck, 2008; Disner etal., 2011; Drevets,
2000; Hamilton etal., 2013; Mayberg, 1997). These can
be exacerbated over time due to neural atrophy resulting from the impact of stress on the brain.
Personality level: The cluster of depressogenic beliefs
produce negative cognitive appraisals, and in turn
hypersensitivity to negative events/stressors. The interaction of these schemas with stress results in the catastrophic loss of self-esteem and negative expectations
(Beck, 1967, 1976).
Neurochemical level: Negative cognitive appraisals
result in hypercortisol secretion (Denson etal., 2009;
Gaab etal., 2005). These appraisals can also lead to
immune or parasympathetic activation (Denson etal.,
2009; Lin etal., 2011), which contribute to anorexia,
anergia, and anhedonia (sickness behavior) that promote energy conservation (Durisko etal., 2015). Dysregulation of several neurotransmitters systems, in
particular monoamines (e.g., serotonin, dopamine),
likely play a mediating role in these processes as well.
Evolutionary framework: The perceived loss of a vital
resource triggers a drastic energy conservation strategy
in effort to promote survival (Beck, 1993). Other mammal species exhibit similar symptoms/reactions when
exposed to the kinds of event that precipitate depression in humans (events that simulate loss of a close
relationship, loss of status, or exclusion from the group).

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A Unified Model of Depression

13

Depressogenic Beliefs
i.e., the Negative Cognitive Triad

Stressor(s)

Negative Cognitive Appraisals

Preemptive Meaning = Loss of Investment
in Vital Resource(s)

Negative Automatic
Thoughts

Autonomic &
Immune Responses

()

()

Cognitive & Emotional

Symptoms
e.g., Sadness, Worthlessness,
Suicidal Ideation

Sickness Behaviors
e.g., Anergia, Anorexia, Anhedonia

+ Vigilance

Key Reversal (vs. Maintenance) Factors = Restructuring (vs. Rumination),

Problem-Solving (vs. Avoidant Coping), Social Support (vs. Conflict)

Overarching Function of the Depression Program = Energy Conservation

Fig. 2.Precipitation, manifestation, and maintenance of the depression program. According to the
model, precipitating stressors and depressogenic beliefs interact to generate negative cognitive appraisals. If the individual perceives that he or she has lost a vital investment, various processes are initiated
in service of energy conservation to compensate for this loss. Specifically, these processes consist of
(a) negative automatic thoughts that generate cognitive and emotional symptoms (e.g., sadness, feelings of worthlessness) and (b) autonomic and immune responses resulting in sickness behaviors
(e.g., anorexia, anhedonia) coupled with vigilance. Furthermore, depressogenic beliefs are reinforced/
strengthened. Once this program is activated, a number of factors can determine if/when it is terminated, including the individuals available support as well as engagement in cognitive restructuring or
problem-solving. However, these processes are undermined by depressogenic beliefs. The converse
processes that serve to maintain the depression program (e.g., ruminative thinking, social conflict) can
generate additional stress for the individual. () indicates proposed negative relationships/effects.

Clinical framework: The clinical features of severe

depression result from extreme deactivations of positive schemas and activations of negative ones. If and
when these (de)activations reach a certain level (often
due to cognitive distortions), the pull to conserve
energy can overcome the individual, which undermines adaptive coping and results in clinically significant impairment.
This article is intended to show the synchrony between
the psychological and biological findings in normal adaptation and in the predisposition to and precipitation of
severe depression. All of the findings related to depression can be joined together to provide a comprehensive
model of the disorder that explains its puzzling features.
The unified model is summarized in Figures 1 and 2.
The progression or sequence begins with genetic risk/

protective factors and childhood trauma, which (alone,

or in combination) lead to stress reactivity and negative
cognitive biases, reflected in structural and functional
brain alterations. Ultimately, this can lead to the development of negative beliefs about the self, world, and future
(the negative cognitive triad). In turn, these beliefs accentuate the impact of the negative life experiences or stressors by shaping individuals appraisal of their meaning.
When a perceived loss of an investment in a vital resource
(often in response to an event or stressor), the depression program is initiated. Specifically, negative thoughts
trigger consistent emotions (e.g., sadness, guilt) as well
as behavioral responses (e.g., withdrawal, inactivity, vigilance). Furthermore, activations of the immune and autonomic nervous systems promote sickness behaviors
(e.g., loss of appetite, anhedonia). The overarching function of this program is to promote the conservation of

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14
energy, in response to the perceived loss. Prolonged activation of this program can result in consolidation/reinforcement of depressogenic beliefs coupled with neural
atrophy in key cognitive brain structures, thus exacerbating future risk.
Figure 2 also highlights several factors that seem to
play a key role in symptom course and prognosis, and
thus we argue are important in determining whether the
depression program is maintained or terminated. These
factors are reviewed in the next section, which briefly
discusses recovery or reversal processes.

Reversing the Depression Program

The depression program can be terminated through the
restoration of resources, resulting from situational
changes or active problem-solving by the individual. But
evolutionary programs can be reversed when corrective
interpretations occur. For example, in the fight/flight
response, the individual may learn that what seemed like
a threat is actually innocuous. Similarly, the depression
program is flexible, and can be terminated if the cognitive appraisal turns out to be inaccurate. This can occur
when the individual spontaneously makes a correction
based on new information. To facilitate this, behavioral
flexibility is often crucial, as coping responses motivated
by the depressive program (e.g., social withdrawal) generally interfere with exposure to corrective information.
Similarly, reversal can occur through reflective/elaborative processing by the individual that fosters cognitive
reappraisal (see Beevers, 2005; Troy, Wilhelm, Shallcross,
& Mauss, 2010). To facilitate these reversal processes,
support from others is beneficial, as evidenced by the
buffering effects of social support (see Cohen & Willis,
1985; Kaufman et al., 2004) and, conversely, elevated
risk of recurrence associated with criticism by loved
ones (e.g., Hooley & Teasdale, 1989). However, depressogenic beliefs (and the other predisposing factors
discussed earlier) can potentially undermine these processes. For example, the individual may ignore or discount information provided by others that it inconsistent
with his or her beliefs. Thus, these beliefs not only
playa key role in the initiation of the depression program, but also can serve to maintain it. Alternatively,
beliefs that support processes such as problem-solving
(e.g., DZurilla, Chang, Nottingham, & Faccini, 1998;
Nezu, 1986), restructuring (e.g., Beevers & Meyer, 2004;
Papageorgiou & Wells, 2009), and support seeking/
utilization (e.g., Collins & Feeney, 2000; DeFronzo,
Panzarella, & Butler, 2001) will promote resilience/
recovery. More generally, the belief that people have the
potential to change/develop seems to promote adaptive
coping and may buffer against depression (e.g., Miu &
Yeager, 2015; see Dweck & Elliott-Moskwa, 2010).

It is important that these same termination processes

can be facilitated through psychotherapy. The engagement with the therapist may be very powerful and in itself
help to modify thoughts of worthlessness, helplessness,
and hopelessness that keep the depressive program
going. In line with this idea, psychotherapy research suggests that these nonspecific factors account for about
half of the change observed in treatment (Cuijpers etal.,
2012). Of course, specific psychotherapy techniques have
been shown to be important as well (particularly for those
with more severe symptoms; see Driessen, Cuijpers, Hollon, & Dekker, 2010). For example, cognitive restructuring
can help change distorted appraisals to more realistic
ones. Of note, this can often occur as a result of effective
action (as opposed to, for example, Socratic questioning)
that contradicts the belief of being incapable (Beck, Rush,
Shaw, & Emery, 1979). For example, depressed individuals who want to stay in bed because of the evolutionarily
mandate to rest generally feel better when they return to
engaging in important activities (e.g., work). There is now
compelling evidence from extensive clinical trials that
these sorts of cognitive and behavioral strategies can have
strong and lasting effects on depressogenic thoughts and
beliefs (e.g., Cristea etal., 2015; Lorenzo-Luaces, German,
& DeRubeis, 2015).
Of course, biological treatments can also help alleviate
the symptoms of depression. Most notably, antidepressant medications can be effective (again, particularly in
more severe cases; see Fournier etal., 2010). In line with
our unified model, there is evidence that a primary
mechanism of action for some antidepressant medications may be the promotion of neurogenesis in brain
areas such as the hippocampus (see, e.g., Tanis, Newton,
& Duman, 2007), which in turn quells HPA dysregulation
(see Barden, Reul, & Holsboer, 1995) and possibly negative information processing biases (see Harmer, Goodwin,
& Cowen, 2009). These changes seem to precede symptom improvement, and we hypothesize that they may
help promote the processing of corrective information. Of
course, like psychotherapy, positive expectations may
play a key role in the therapeutic effects of these medications, as evidenced by robust placebo effects in antidepressant medication trials (particularly for those with less
severe symptoms; see Kirsch etal., 2008).
More generally, a number of promising treatment/prevention approaches for depression exist (a full discussion
of which is beyond the scope of this article), and our
model suggests that any intervention that targets key predisposing, precipitating, or resilience factors can reduce
risk or alleviate symptoms. These include a variety of
psychotherapeutic approaches, such as problem-solving
therapy (Nezu, Nezu, & Perri, 1989), acceptance and
commitment therapy (Hayes, 2004), and mindfulnessbased interventions (Segal, Williams, & Teasdale, 2012). It

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A Unified Model of Depression

15

is important that current evidence supports the notion

that interventions that directly target proximal cognitive
factors have the most reliable prophylactic effect (e.g.,
Hollon, Stewart, & Strunk, 2006; Rohan, Roecklein, Lacy,
& Vacek, 2009; Segal etal., 2006). In further support of
our integration across levels of analysis, changes that
result from such treatments can also be observed in
altered functioning in relevant brain regions (e.g., hippocampus, prefrontal cortex; Beevers, Clasen, Enock, &
Schnyer et al., 2015; Goldapple et al., 2004; see DeRubeis, Siegle, & Hollon, 2008) as well as endocrine/
immune responses (e.g., cortisol levelsAntoni et al.,
2000; Gaab etal., 2003; inflammationGazal etal., 2013;
Moreira etal., 2015). In turn, some promising efforts are
under way to develop novel interventions for depression
that capitalize on recent advances in our understanding
of specific cognitive and neurobiological mechanisms
discussed earlier (e.g., Beevers et al., 2015; De Raedt,
Vanderhasselt, & Baeken, 2015; Siegle etal., 2014).

Conclusions and Future Directions

In this article, we have presented a unified model of
depression, integrating the clinical features with cognitive
theory, recent advances in the neurobiology of this phenomenon, and evolutionary perspectives. Our motivation
for doing this was to incorporate new findings that have
emerged since previous models were published (e.g.,
Beck, 2008), but more important, present an account that
would integrate seemingly disparate work across different
frameworks and levels of analysis in a cohesive, coherent,
and novel fashion. We also briefly reviewed some
approaches to alleviating depression and how they fit
within our model. In turn, we hope that this model will
motivate further development of new (and more integrative) approaches for treating or preventing depression
(see, e.g., De Raedt etal., 2015; Siegle etal., 2014).
Of course, like any theoretical model, the proposed
model should be viewed as tentative, to be systematically
evaluated and refined/expanded based on new research
findings. In fact, given the ambitious goals of this undertaking, it is not surprising that some aspects of the model
are relatively speculative. For example, direct evidence for
the central mediating role of depressogenic beliefs/schemas in links between information processing, stress reactivity, and depression has proven difficult to obtain, in
part because these beliefs/schemas are considered to
remain dormant until activated along with symptoms.
This could be addressed in future research with priming procedures (e.g., mood inductions; see Gotlib &
Krasnoperova, 1998; Lau et al., 2004) or using psychophysiological measures that might be sensitive to these
vulnerabilities (e.g., neuroimagingZhong et al., 2011;
eye trackingSears, Newman, Ference, & Thomas, 2011).

In turn, such methods of assessing cognitive vulnerability

could be examined in studies to determine their predictive
power, and ultimately could be used as selection and outcome measures when developing and testing new preventive interventions. This work not only would have clear
and significant clinical implications, but also would provide important confirmation for key aspects of the model.
More generally, despite major advances in our understanding of the nature and etiology of depression over
the past five decades, many important questions remain
unanswered. Although it would be unfeasible to discuss
them all here, we highlight a few general directions that
we consider important to pursue in future research, motivated by our unified model.
1. First and foremost, we hope this model will stimulate more integrative research examining multiple
levels of analysis (e.g., cognitive, genetic, neural,
hormonal) within the same study (see, e.g., Gotlib
etal., 2008). Such work would also fit nicely with
the National Institute of Mental Healths Research
Domain Criteria initiative, several aspects of which
have clear and strong relevance to depression and
our model (e.g., loss, reward responsivity).
2. Largely for practical reasons, a bulk of research
exploring the neurobiology of depression has
been cross-sectional. As biological methodologies
continue to become more affordable, we hope
that more longitudinal work will be done to
explore how neurobiological aspects of depression unfold over time (e.g., structural abnormalities in the hippocampus), and how this relates to
cognitive changes/risk.
3. Additional research is needed to determine whether
a single model of depression will ever suffice to
account for all clinical cases, or instead whether
there are distinct subtypes with meaningfully divergent etiological pathways (e.g., Gold, MachadoVieira, & Pavlatou, 2015). If such heterogeneity
were confirmed, it would be critical for future
(basic and applied) research to account for this.
4. Although we provided some brief speculations
about how treatments for depression might work
within the context of our model, the fact remains
that our understanding of the key change
mechanism(s) in treatments for severe depression is
largely speculative. Although this has been explored
for a few more established treatment approaches
(e.g., cognitive therapy, antidepressant medication;
see DeRubeis et al., 2008), it will be particularly
important to carefully test putative mechanisms
(both psychological and biological) for more
recently established ones (e.g., mindfulness-based
interventions, transcranial magnetic stimulation).

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Beck and Bredemeier

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Ultimately, a better understanding of the mechanisms involved in these treatments not only would
help us refine them, but also could help foster the
optimization of individual treatment plans (in service of precision medicine).
5. Perhaps due to the dominance of the disease
model, we feel that the topic of resilience has
been relatively understudied. For example, it
would be interesting to carefully study the cognitive and biological characteristics of individuals
who experience significant losses yet due not
become severely depressed, as well as those who
recover quickly without formal treatment (see,
e.g., Charney, 2014). Such work would have
important implications for validating/refining our
unified model, and also direct clinical implications
(see, e.g., Waugh & Koster, 2015).
Author Contributions
A. T. Beck developed the framework of the model and wrote
the initial draft of the manuscript. K. Bredemeier assisted in
reviewing key literatures and updating the model/manuscript.
The authors worked closely together to complete final revisions
and edits, as well as incorporate feedback from colleagues.

Acknowledgments
The authors would like to thank Greg Siegle, Connie Hammen,
George Slavich, David A. Clark, Dwight Evans, Stefan Hofmann,
Robert Leahy, Steve Hollon, Rob DeRubeis, Christopher
Beevers, Brandon Gibb, Ken Kendler, Paul Andrews, Michael
Thase, Jay Fournier, Jay Schulkin, Kelly Rohan, Lorenzo
Lorenzo-Luaces, Greg Brown, Abby Adler, Shari Jager-Hyman,
Kelly L. Green, Ben Rosenberg, Elaine Elliott-Moskwa, and
Adam Rifkin for their feedback on our model and preliminary
drafts of the manuscript. Also, we would like to thank Robyn
Himelstein for her assistance with literature reviews.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interest with
respect to their authorship or the publication of this article.

2. From this point on, discussions of resources or vital

resources reference these.
3. We define stressors broadly, as any significant change that
an individual must adjust to. This includes life situations as well
as biological insults (e.g., an infection; see Dantzer, OConnor,
Freund, Johnson, & Kelley, 2008; Yirmiya etal., 2000).
4. As we allude to here, there is evidence that many of the
predisposing factors discussed in the model are not unique
to depression, but rather are common across multiple (if not
most) forms of psychopathology (e.g., MacMillan etal., 2001;
Psychiatric Genomics Consortium, 2013). Although there is evidence for specificity regarding the proximal cognitive precipitants (e.g., of depression vs. anxiety; see Beck & Clark, 1988;
Hankin, Abramson, Miller, & Haeffel, 2004), a discussion of this
work is beyond the scope of our article.
5. The prominence of this neural atrophy within the hippocampus is evidenced by a documented negative association
between hippocampal volume and depression duration (e.g.,
Sheline, Wang, Gado, Csernansky, & Vannier, 1996), and may
be due to the high concentration of glucocorticoid receptors in
this brain region (possibly to promote specific enhancements in
cognition during acute stress; see McEwen & Sapolsky, 1995).
6. Seasonal depression appears to be linked with the same
distal risk factors (e.g., the 5-HTTLPR short variant; Rosenthal
etal., 1998) and proximal risk factors (e.g., negative automatic
thoughts; Rohan, Sigmon, & Dorhofer, 2003) as nonseasonal
depression. Thus, we propose that our unified model is also
applicable to cases/episodes with a seasonal pattern (but see
Rohan, Roecklein, & Haaga, 2009, for an integrative review/
model focused on seasonal depression). In fact, seasonal
depression could be consider a prototypical manifestation of
the evolutionarily derived depression program that we propose, given the notable connections with energy conservation
and access to vital resources (e.g., supporting reproduction)
that have been discussed (e.g., Davis & Levitan, 2005).
7. It is important to note that there is also evidence for immune
suppression in depression (Blume, Douglas, & Evans, 2011), in
line with established links among stress, cortisol, and immune
functioning (see, e.g., Selye, 1973). However, immune activation and suppression are not mutually exclusive, and may even
be interrelated in important ways (see, e.g., Blume etal., 2011;
Segerstrom, 2007).

References
Funding
This work was supported in part by the Fieldstone 1793
Foundation.

Notes
1. It is well established that depressive disorders are more common in females (APA, 2013). Nevertheless, the model does
explicitly not address these gender differences, based on evidence suggesting that the same factors are involved in the etiology of depression for both genders, but some are simply more
common in females (e.g., Hamilton, Stange, Abramson, & Alloy,
2015; Nolen-Hoeksema, Larson, & Grayson, 1999; see NolenHoeksema & Girgus, 1994). Thus, we propose that our model is
applicable to depression in both males and females.

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