Major Depressive Disorder

Major Depressive Disorder

Major Depressive Disorder

Major depressive disorder (MDD) — also known as clinical depression, unipolar depression, recurrent depression, or simply depression — is a mental disorder characterized by the presence of a severely low mood of no clear cause that persists for at least two weeks and which pervades across most, if not all, aspects of life.

While it can be hard to hope in recovery during a severe depressive episode, great strides have been made in helping people feel better thanks to thoughtful treatment plans and more understanding of the disorder. When in a depressive episode, it is wise to wait until one is in a better state of mind before making important, life-changing decisions.

Prevalence

The onset of MDD can occur in children and adolescents and in younger and older adults. MDD most commonly occurs between 20 and 40 years of age, and women are twice as likely as men to be diagnosed with it. Lifetime rates of MDD are higher in the developed world (15%) compared to the developing world (11%). According to the Global Burden of Disease study, MDD causes the second-most years lived with a disability, after lower back pain.

Symptoms of Depression:

The two main symptoms of MDD are:

  • Feeling very low, sad, tearful, hopeless, and empty
  • Anhedonia – loss of interest or pleasure in activities previously enjoyed and withdrawal from participating in conversations or being engaged in any setting

People with MDD may also:

  • Be preoccupied with thoughts and feelings of worthlessness, helplessness, hopelessness, guilt, self-criticism, and self-hatred
  • Have suicidal thoughts and attempts
  • Display outbursts of anger and get very irritable and frustrated over minor things
  • Be very low on energy, feeling too low to try to do anything, no motivation
  • Have difficulty thinking, remembering, processing thoughts, concentrating, asking decisions, handling conflict
  • Show physical symptoms – may report multiple physical symptoms such as fatigue, headaches, back pain, small appetite or overeating, insomnia, too much sleep, or digestive problems
  • Display psychosis in severe cases – delusions or hallucinations

Children and adolescents with MDD might appear more irritable than seem depressed. They aren’t interested in schoolwork, and their academic performance can plummet. Children in particular can appear insecure, anxious, or unwilling to be alone.

Older adults with MDD might have recent cognitive function issues such as memory problems. MDD in older adults often coexists with physical disorders such as stroke, Parkinson’s disease, chronic obstructive pulmonary disease, and cardiovascular diseases.

Diagnosing Depression:

For a diagnosis of MDD to be made, the symptoms above, as well as three out of seven of the following symptoms, must frequently occur for at least two weeks — and they must impair functioning:

  • Weight loss or gain – greater than a 5% change in a month
  • Insomnia or hypersomnia – sleeping too little or too much
  • Unintentional movements and restlessness or retardation
  • Tiredness or loss of energy
  • Feeling worthless or feeling excessive or inappropriate guilt
  • Decreased concentration
  • Thoughts of suicide

Episodes of MDD may be isolated or recurrent and are categorized as:

  • Mild — few symptoms in excess of minimum criteria
  • Moderate
  • Severe — marked impact on social, academic, or occupational functioning. An episode with psychotic features — commonly referred to as psychotic depression — is automatically rated as severe.

Causes of Depression:

The cause of MDD has a few possible but unconfirmed causes:

  • Biological – Visible physical changes in the brain are sometimes seen with brain imaging. Hormone irregularities can cause depression.
  • Brain chemistry – Neurotransmitters don’t work as well to maintain mood stability in the brains of those with MDD.
  • Genetic – MDD is about 40% more common when a mood disorder has been diagnosed in other family members.

Risk factors for Depression:

Some people seem to be more predisposed to an MDD episode if they:

  • Are used to being negative and thinking negative thoughts about themselves and everything around them
  • Abuse or depend on alcohol or drugs
  • Are LGBTQ with no support from family or friends
  • Are experiencing chronic pain or a chronic illness
  • Have been in circumstances that can make someone feel helpless, like poverty, trauma, loss, and abuse
  • React to certain medications or drug combinations
  • Are a mix of two or more races

Treatment of Depression:

Major depressive disorder has shown the best results from treatment when medication and psychotherapy are combined. Improvement is gradual, not immediate, due to the time it takes to find the right medication and wait for it to be effective.

  • Major depressive disorder has shown the best results from treatment when medication and psychotherapy are combined. Improvement is gradual, not immediate, due to the time it takes to find the right medication and wait for it to be effective.
  • Admission – (which may be involuntary) to a psychiatric hospital — until symptoms stabilize — may be necessary if a person poses a risk to him/herself and/or to others. An outpatient treatment program might also be an option in order to formulate a good treatment plan and empower the person with support and therapy.
  • Antidepressant medications – A psychiatrist will need to prescribe different medications until the person finds one that is the most effective and gives the fewest side effects. There is a danger of some antidepressants increasing suicidal thoughts and behaviour, especially when the meds are switched or starting, so symptoms must be monitored carefully over the first 4 to 6 weeks.

    • Selective serotonin reuptake inhibitors (SSRIs) such as escitalopram or citalopram will take up to two months to become therapeutically effective.
    • Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as mirtazapine or bupropion.
    • Tricyclic antidepressants (TCAs) and monoamine inhibitors can be prescribed if the newer medications are not effective.
    • Intranasal ketamine is an FDA-approved treatment for people with treatment-resistant depression, and it must be administered by a medical professional in a clinical setting.
  • Talk therapy (psychotherapy) – such as:

    • Cognitive behavioral therapy (CBT) – helps people recognize triggers and adopt healthy ways to respond, plus ways to change negative thought patterns for positive ones.
    • Cognitive behavioral analysis system of psychotherapy (CBASP) – helps people stop avoiding others in order to feel safe. Teaches skills to stay mentally present and engaged in social settings rather than withdraw mentally.
    • Interpersonal psychotherapy/problem-solving therapy – 3- to 4-month therapy that helps people stop letting life circumstances dictate their mood and teaches problem-solving skills and strategies to face and process them.
  • Electroconvulsive Therapy (ECT) – might be used if nothing else seems to be working or the person cannot take medications. It basically shocks the brain by sending an electrical current through the brain.
  • Transcranial Magnetic Stimulation (TMS) – is non-invasive brain stimulation (currently in the testing phase) for those who are not good candidates for other treatments or medications. It is used alongside psychotherapy.
  • Individual and family therapy – can help a person with MDD process past and current conflict and trauma and learn effective communication skills to grow future relationships in a healthy way.
  • Life coaching – helps people set realistic goals for their lives and take consistent steps toward achieving them.
  • Lifestyle modification – increased exercise, staying active, eating healthy food, being deliberately relational, and getting enough regular sunlight play a role in prevention.

Approximately 2 to 8% of adults with MDD die by suicide, and about 50% of people who die by suicide had MDD or another mood disorder. If you are experiencing suicidal thoughts, you can call the Suicide Prevention Hotline and talk for free at 1-800-SUICIDE (1-800-784-2433) or 1-800-273-TALK (1-800-273-8255). They can also provide you with information about low-cost clinics and therapists for your depression.

Call 911 if you are seriously contemplating or vocalizing thoughts of suicide or self harm.

Symptoms of Depression:

The two main symptoms of MDD are:

  • Feeling very low, sad, tearful, hopeless, and empty
  • Anhedonia – loss of interest or pleasure in activities previously enjoyed and withdrawal from participating in conversations or being engaged in any setting

People with MDD may also:

  • Be preoccupied with thoughts and feelings of worthlessness, helplessness, hopelessness, guilt, self-criticism, and self-hatred
  • Have suicidal thoughts and attempts
  • Display outbursts of anger and get very irritable and frustrated over minor things
  • Be very low on energy, feeling too low to try to do anything, no motivation
  • Have difficulty thinking, remembering, processing thoughts, concentrating, asking decisions, handling conflict
  • Show physical symptoms – may report multiple physical symptoms such as fatigue, headaches, back pain, small appetite or overeating, insomnia, too much sleep, or digestive problems
  • Display psychosis in severe cases – delusions or hallucinations

Children and adolescents with MDD might appear more irritable than seem depressed. They aren’t interested in schoolwork, and their academic performance can plummet. Children in particular can appear insecure, anxious, or unwilling to be alone.

Older adults with MDD might have recent cognitive function issues such as memory problems. MDD in older adults often coexists with physical disorders such as stroke, Parkinson’s disease, chronic obstructive pulmonary disease, and cardiovascular diseases.

Diagnosing Depression:

For a diagnosis of MDD to be made, the symptoms above, as well as three out of seven of the following symptoms, must frequently occur for at least two weeks — and they must impair functioning:

  • Weight loss or gain – greater than a 5% change in a month
  • Insomnia or hypersomnia – sleeping too little or too much
  • Unintentional movements and restlessness or retardation
  • Tiredness or loss of energy
  • Feeling worthless or feeling excessive or inappropriate guilt
  • Decreased concentration
  • Thoughts of suicide

Episodes of MDD may be isolated or recurrent and are categorized as:

  • Mild — few symptoms in excess of minimum criteria
  • Moderate
  • Severe — marked impact on social, academic, or occupational functioning. An episode with psychotic features — commonly referred to as psychotic depression — is automatically rated as severe.

Causes of Depression:

The cause of MDD has a few possible but unconfirmed causes:

  • Biological – Visible physical changes in the brain are sometimes seen with brain imaging. Hormone irregularities can cause depression.
  • Brain chemistry – Neurotransmitters don’t work as well to maintain mood stability in the brains of those with MDD.
  • Genetic – MDD is about 40% more common when a mood disorder has been diagnosed in other family members.

Risk factors for Depression:

Some people seem to be more predisposed to an MDD episode if they:

  • Are used to being negative and thinking negative thoughts about themselves and everything around them
  • Abuse or depend on alcohol or drugs
  • Are LGBTQ with no support from family or friends
  • Are experiencing chronic pain or a chronic illness
  • Have been in circumstances that can make someone feel helpless, like poverty, trauma, loss, and abuse
  • React to certain medications or drug combinations
  • Are a mix of two or more races

Treatment of Depression:

Major depressive disorder has shown the best results from treatment when medication and psychotherapy are combined. Improvement is gradual, not immediate, due to the time it takes to find the right medication and wait for it to be effective.

  • Admission – (which may be involuntary) to a psychiatric hospital — until symptoms stabilize — may be necessary if a person poses a risk to him/herself and/or to others. An outpatient treatment program might also be an option in order to formulate a good treatment plan and empower the person with support and therapy.
  • Antidepressant medications – A psychiatrist will need to prescribe different medications until the person finds one that is the most effective and gives the fewest side effects. There is a danger of some antidepressants increasing suicidal thoughts and behaviour, especially when the meds are switched or starting, so symptoms must be monitored carefully over the first 4 to 6 weeks.

    • Selective serotonin reuptake inhibitors (SSRIs) such as escitalopram or citalopram will take up to two months to become therapeutically effective.
    • Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as mirtazapine or bupropion.
    • Tricyclic antidepressants (TCAs) and monoamine inhibitors can be prescribed if the newer medications are not effective.
    • Intranasal ketamine is an FDA-approved treatment for people with treatment-resistant depression, and it must be administered by a medical professional in a clinical setting.
  • Talk therapy (psychotherapy) – such as:

    • Cognitive behavioral therapy (CBT) – helps people recognize triggers and adopt healthy ways to respond, plus ways to change negative thought patterns for positive ones.
    • Cognitive behavioral analysis system of psychotherapy (CBASP) – helps people stop avoiding others in order to feel safe. Teaches skills to stay mentally present and engaged in social settings rather than withdraw mentally.
    • Interpersonal psychotherapy/problem-solving therapy – 3- to 4-month therapy that helps people stop letting life circumstances dictate their mood and teaches problem-solving skills and strategies to face and process them.
  • Electroconvulsive Therapy (ECT) – might be used if nothing else seems to be working or the person cannot take medications. It basically shocks the brain by sending an electrical current through the brain.
  • Transcranial Magnetic Stimulation (TMS) – is non-invasive brain stimulation (currently in the testing phase) for those who are not good candidates for other treatments or medications. It is used alongside psychotherapy.
  • Individual and family therapy – can help a person with MDD process past and current conflict and trauma and learn effective communication skills to grow future relationships in a healthy way.
  • Life coaching – helps people set realistic goals for their lives and take consistent steps toward achieving them.
  • Lifestyle modification – increased exercise, staying active, eating healthy food, being deliberately relational, and getting enough regular sunlight play a role in prevention.

Approximately 2 to 8% of adults with MDD die by suicide, and about 50% of people who die by suicide had MDD or another mood disorder. If you are experiencing suicidal thoughts, you can call the Suicide Prevention Hotline and talk for free at 1-800-SUICIDE (1-800-784-2433) or 1-800-273-TALK (1-800-273-8255). They can also provide you with information about low-cost clinics and therapists for your depression.

Call 911 if you are seriously contemplating or vocalizing thoughts of suicide or self harm.

Sources MAYO CLINIC | NIH – Depression | NIH – Major Depression | NIH – Depression Medication | ARCHIVE.org – DSM-5 Major Depressive Disorder