Major depressive disorder is an episodic illness defined by feelings of intense sadness, misery, and/or hopelessness. It can include feelings of numbness, discontent, pessimism, and indifference to the world, as well as pervasive shame, guilt, worthlessness, and suicidal plans or attempts. Symptoms must present for a minimum of two weeks to confirm a diagnosis, but most bouts last far longer.
Also known as major or clinical depression, MDD is the depressed mood we most readily recognize. It’s stamped on a sad face, drawn in dark circles under sleepless eyes, and startling in dramatic weight gains or losses. It steals joy, desire, energy and self-confidence from those in its grip; it thwarts their ability to cope with life and to make plans.
Sometimes a major depressive episode is a once-in-a-lifetime event. For the majority of cases, though, one episode is just the first.
Causes and Risk Factors
What causes major depression remains a medical mystery, but researchers have their suspects. Understanding how the following factors influence our brains and bodies is unlocking clues to the origins of the disorder.
Brain-imaging technologies have shown that depressed brains look different than other brains.
Neurotransmitters such as serotonin and norepinephrine may influence circuits in the brain responsible for mood stability (or the lack thereof).
Imbalances brought on by pregnancy and delivery, menopause, thyroid problems, or even chronic stress may cause depression.
According to family studies, the lifetime risk of developing MDD doubles or may even triple when a parent, sibling, or child has it, too.
Negative qualities such as low self-esteem, dependence on others, pessimism and self-criticism can increase depression risk.
A distressed childhood, or life events such as grief, violence, neglect, abuse or poverty can lead to MDD.
A head start
Depression that began in childhood or adolesence ups the odds it will re-emerge in adulthood.
Major depression often compounds illnesses such as cancer, stroke, chronic pain, heart disease, or other mental health disorders involving anxiety, eating, or post-traumatic stress.
Misuse of alcohol or drugs can trigger major depression; so can some prescription medications for high blood pressure or sleep problems.
Diagnosing Major Depressive Disorder
All forms of clinical depression wave two red flags: a persistently low mood and a loss of interest in previously enjoyable activities. Any diagnosis of MDD must include at least one of these two main symptoms.
- Low mood. Patients feel sad and hopeless most of the time on most days. This can appear in children and adolescents as irritability.
- Lost interest. Favorite activities, even eating and sex, can lose their appeal when someone is depressed. They may even lose the ability to experience pleasure or love. The medical term for this state of feeling is “anhedonia”.
Other symptoms of MDD include the following:
- Appetite changes. Many people with depression lose weight due to a poor appetite. Some gain weight because their appetite increases.
- Sleep problems. Some individuals have trouble falling or staying asleep, often waking up early in the morning, unable to get back to sleep. Others sleep excessively.
- Movement changes. Some individuals have trouble falling or staying asleep, often waking up early in the morning, unable to get back to sleep. Others sleep excessively.
- Lack of energy. Fatigue is a common sign of depression, as is a loss of mental quickness. Even routine tasks become difficult to perform.
- Hopelessness or guilt. These patients are stuck with a bleak world view or the belief that nothing will ever get better.
- Poor concentration. People in a deep depression may lose their ability to think critically or make decisions. They may struggle to follow conversations, read, or watch TV.
- Thinking of suicide. People can feel like their depression will never end, that there is no light at the end of the tunnel. Some start to think that the only way out is through death, and this leads to recurrent thoughts of dying, planning suicide, and suicide attempts.
Some people with depression will exhibit just a few of these symptoms; others, many more. A clinician will diagnose MDD when at least four of these additional symptoms accompany low mood or loss of interest for a minimum of two weeks.
Treating Major Depressive Disorder
MDD responds well to treatment, yet less than half of the millions of people who meet the diagnostic criteria for depression seek help each year. Most of them will gain some symptom relief from the many treatment options available.
The most well known type is SSRIs (selective serotonin reuptake inhibitors), which are the first line of defense in the battle against depression. This well-established class of medications improves brain chemistry by boosting levels of beneficial neurotransmitters such as serotonin and norepinephrine. Antidepressants aren’t habit-forming, but can produce withdrawal symptoms if stopped abruptly. Patients may need to try out a few different drugs and doses before finding the one(s) that work best for them.
This involves the verbal exploration of what causes depression. Insights acquired in a supportive setting can help patients identify negative behaviors, improve personal relationships, and develop coping skills that promote recovery. Research shows that people with depression do best when treated with both medication and a course of psychotherapy.
These can be effective ways to tackle severe depressions or cases that don’t respond well to other treatments. These interventions include Transcranial Magnetic Stimulation (TMS), Electroconvulsive Therapy (ECT), Vagus Nerve Stimulation (VNS), and Deep Brain Stimulation (DBS).
Complementary and alternative medicines
Often referred to as CAM, these are increasingly popular adjuncts to conventional medicine. New evidence suggests that the omega-3 fatty acids in fish oil, SAM-e, methylfolate, and vitamin D work well with antidepressants to reduce symptoms of depression when taken under medical supervision. Other promising therapies include acupuncture, meditation, yoga, and other forms of exercise.
Managing Major Depressive Disorder
Major depression is no minor diagnosis. If denied or left untreated, it can lead to broken relationships, lost jobs, and even suicide.
MDD doesn’t have to get that far. Keeping a low mood from spiraling into a high-stakes depressive episode may just make the difference between hell and a healing place. Even severe depression can respond to well-timed treatment.
Need to help someone in the throes of depression? Consider these interventions.
Thoughts of death and dying, hallucinations, personal neglect, or a desire to cause harm to themselves or others are real medical emergencies that need immediate attention.
Coordinate clinical care
Secure from the patient’s primary care physician a referral to a mental health professional. Request a current medication list to bring to the consultation. And stay in touch: Patient outcomes improve when primary care and specialties work together on follow-up.
The temptation to dull pain with drugs and alcohol may be strong, but it will only make matters worse. Substance abuse makes depression harder to recognize and treat.
Cast a wide net
Technology can reach people in remote areas who might otherwise lack access to mental health services. Talk with a local health care provider about the emerging field of therapist-guided Internet-based cognitive behavioral therapy (iCBT).
Medications can take up to two to four weeks to start working, and six to 12 weeks to take full effect. Keep in mind that family and friends are often the first to notice improvements.
Remember that depression is a treatable disease, not a sign of weakness.