Major Depressive Disorder

What is major depressive disorder?

Major depressive disorder (MDD) is a serious mood disorder. It is much deeper than just feeling sad or depressed on a given day or week. It’s defined by continual sadness and loss of enjoyment in daily life that lasts for more than 2 weeks. Depression changes how you experience the world and comes with a variety of physical symptoms as well. It is also called clinical depression.

MDD affects 7% of adults. It can happen at any age, and in children as well. But it usually begins in the teens or 20’s. It is treated with therapy or a combination of therapy and medications. More than 80% of people improve with treatment.

Most common symptoms

People with major depressive disorder often talk about feeling sad all the time, often crying, and having a hard time getting out of bed. Their sleep is not regular (sleeping more or less than usual). They feel sluggish, have less energy, and are not interested in things they usually enjoy.

MDD can range from mild to severe. Many people will experience depression at some point in their lives and feel sad and not like themselves. But they can function relatively normally. In more severe cases, people pull away from the world and have a hard time even leaving their bed. They say everything feels like they are "walking through mud" and they may experience brain fog. It can also affect their appetite and weight.

Not all depression is MDD. It could be caused by other mental health conditions like bipolar disorder, substance use, or a general medical condition like hypothyroidism.

Main symptoms

• Depressed mood: feeling sad, empty, hopeless, discouraged, or “down in the dumps.”
• Decreased interest or pleasure in most or all activities.
• Unplanned weight loss or weight gain.
• Changes in appetite: may have to force yourself to eat or may crave carbohydrate-rich foods.
• Changes in sleep patterns: trouble falling asleep, waking up in the morning, or may sleep more than usual.
• Restlessness: hard to sit still, pacing, pulling at your skin or hair.
• Slower movement and speech.
• Feeling low energy nearly every day.
• Difficulty concentrating (or focusing).
• Feelings of worthlessness or excessively placing blame on yourself.
• Thoughts that life is no longer worth living.

Next steps

If you’ve felt these symptoms for more than two weeks, seek help. If you feel comfortable talking with your primary care physician, you can start there. They can offer treatment options or recommend that you see a therapist or psychiatrist, who can prescribe medications. Though doctors can treat depression, psychiatrists have more knowledge about medications for mood disorders.

If you or someone you know is having thoughts about ending their life or is unable to take care of themselves due to depression, call 988 (the new Suicide and Crisis Lifeline) or 911, or go to the nearest ER. Get help right away.

What is used to treat major depression?

Treatment may include a combination of therapy, medications, and lifestyle changes. The good news is that 80% to 90% of people with depression eventually respond well to treatment.

Psychotherapy

There are a range of talk therapies that can help reduce symptoms of depression. Cognitive behavioral therapy (CBT) is a popular and well-researched one. It helps you identify negative and unhelpful patterns of thought and helps you make positive changes in your thoughts and behaviors.

Many people with depression can feel an improvement after a few months of weekly therapy sessions. Depending on many factors including the severity of symptoms, you may need to combine therapy with medications.

Medications

There are many antidepressants that treat depression. Your doctor or psychiatrist will recommend the best one for you. They will consider symptoms, other medical conditions, and any concerns about side effects. (Side effects vary in each medication.) It can take up to 2 to 3 months to notice a full positive change from antidepressants. Though for some people positive mood changes in two weeks. You may have to go through some trial and error before finding the right one.

Some medications your doctor might consider:

• Selective serotonin or norepinephrine reuptake inhibitors (SSRIs and SNRIs): SSRIs are usually the first antidepressant that people try. Common ones are fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro). Never stop taking them without checking with your doctor. They will slowly decrease your dose. If you suddenly stop taking SSRIs and SNRIs, you might experience anxiety, irritability, nausea, diarrhea, headaches, and other symptoms.
• Atypical antidepressants: Some medications help with specific symptoms. You may be prescribed bupropion (Wellbutrin) for low energy and poor concentration. Mirtazapine (Remeron) is a good choice if you have very little appetite.
• Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are older antidepressants and are not often used anymore. But your doctor may suggest one if other medications aren’t working. TCAs have more side effects than SSRIs and SNRIs. MAOIs can be hard to take due to strict dietary restrictions. They can also cause reactions with other medications.
• Augmentation: You might need a second medication if your symptoms don’t go away with the antidepressant. Additional treatment options include antipsychotic medication, lithium, and thyroid hormone.

Neuromodulation treatments

When medications and therapy are not effective, neuromodulation techniques, which deliver stimulation directly to the brain, can be tried.

• Electroconvulsive therapy (ECT) is also known as shock treatment. It is used when depression is not responding to other treatments. It causes a short controlled seizure that changes the brain’s chemistry. It can lead to mild memory loss.
• Transcranial magnetic stimulation (TMS) is a newer technique that uses magnetic fields to stimulate brain cells. You might have a mild headache or scalp discomfort.

Follow up

Take medications exactly as prescribed. Continue to see your therapist and have regular check-ins with the doctor prescribing your medication. If you experience side effects, tell your doctor. If you haven’t had symptoms for 6 months or more, you may want to talk to your doctor about the possibility of tapering off your medications. Always check with your doctor first before making any changes to your medications.

Causes of major depressive disorder

Like with most mental health conditions, the reason people develop MMD is complex. There are many biological, psychological, and environmental factors.

• Brain chemistry: Abnormal levels of brain chemicals might affect your mood. Or there could be a hormonal imbalance. Stress, thyroid, or growth hormones may not be working correctly.
• Genetics: Depression runs in families. If someone in your family has had depression, you are more likely to have a depressive episode.
• Environmental or psychosocial stressors: Severe life stressors—separations and losses, and exposure to violence, neglect, abuse, or poverty—can lead to depression.
• Depression often occurs along with substance use, anxiety, personality disorders, and chronic medical conditions (like diabetes, cancer, heart disease).

Depression in children

Children can have depression as well. Depression in children and adolescents may have different symptoms.

• More likely to be irritable than sad.
• Not gaining enough weight as they grow.
• Feelings of boredom.
• Separation anxiety—upset when caregivers leave.
• Physical complaints, such as headache or stomach aches.
• Phobias (specific fears).

Treatments for depression in children and teens are similar to those for adults. Many doctors are reluctant to start with medications for children, and often recommend therapy first. Antidepressants may have side effects and risks so discuss these with your child’s doctor.