Major Depression

Major depression is more than just feeling sad. It is a serious medical condition that affects how you feel, think, and handle daily activities, and it can be effectively treated with the right support.

What is major depression?
Symptoms and signs
Who is affected
What causes major depression
How is it diagnosed
Treatment options
Living with major depression

What is major depression?

Major depression, also called major depressive disorder or clinical depression, is a mental health condition that causes a persistent feeling of sadness and loss of interest in activities that once brought joy^[1]. It is not about being in a bad mood, and people who experience depression cannot just snap out of it^[1].

This condition affects all aspects of life, including relationships with family, friends, and community. It can result from or lead to problems at school and at work^[4]. Depression is different from regular mood changes and feelings about everyday life^[4].

Major depressive disorder has been ranked as the third cause of the burden of disease worldwide in 2008 by the World Health Organization, which has projected that this disease will rank first by 2030^[2]. Globally, an estimated 5.7% of adults suffer from depression, with approximately 332 million people in the world having depression^[4].

major depressive disorder, clinical depression, MDD

Symptoms and signs

Major depression is diagnosed when a person has a persistently low or depressed mood, anhedonia (decreased interest in pleasurable activities), feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation (slowed or restless movement), sleep disturbances, or suicidal thoughts^[2].

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), a person must have five of these symptoms, of which one must be a depressed mood or anhedonia causing social or occupational impairment, to be diagnosed with major depressive disorder^[2]. These symptoms must be present for at least two weeks^[3].

Specific symptoms can include^[3]:

Feeling very sad, empty or hopeless (low mood). Children and adolescents may be irritable rather than sad
Loss of interest in things and activities that used to bring joy
Increase or decrease in appetite, which may result in weight gain or weight loss
Slowed speech, decreased movement and impaired thinking
Trouble sleeping (insomnia) or sleeping too much (hypersomnia)
Low energy or fatigue
Feeling worthless or excessively guilty
Decreased concentration
Thoughts of death or suicide

During a depressive episode, a person experiences these symptoms most of the day, nearly every day^[4]. Depression can cause difficulties in all aspects of life, including in the community and at home, work and school^[4].

Who is affected

Clinical depression can affect anyone, including children and adults. Most cases tend to begin in a person’s 20s, but it can develop at any age^[3]. Depression honestly affects people of all ages and races and biological sexes, income levels and educational backgrounds^[1].

Depression is about 1.5 times more common among women than among men. Worldwide, more than 10% of pregnant women and women who have just given birth experience depression^[4]. Clinical depression is more likely to affect women than men. It is also more common in people without close interpersonal relationships and people who are divorced, separated or widowed^[3].

Approximately one in six people will experience a major depressive episode at some point in their lifetime, while up to 16 million adults each year suffer from clinical depression^[1]. It is one of the most common mental health conditions and affects 5% to 17% of people at some point in their lives^[3].

What causes major depression

The causes of major depressive disorder are believed to be multifactorial, including biological, genetic, environmental, and psychosocial factors^[2].

Major depression was earlier considered to be mainly due to abnormalities in neurotransmitters (chemical messengers in the brain), especially serotonin, norepinephrine, and dopamine. This has been supported by the use of different antidepressants that work on these neurotransmitters in the treatment of depression. People with suicidal thoughts have been found to have low levels of serotonin breakdown products^[2].

However, recent theories indicate that major depression is associated primarily with more complex nerve regulation systems and neural circuits in the brain, causing secondary disturbances of neurotransmitter systems^[2]. Other neurotransmitters, including GABA (an inhibitory neurotransmitter), and glutamate and glycine (both excitatory neurotransmitters), are also found to play a role^[2].

People who have lived through abuse, severe losses or other stressful events are more likely to develop depression^[4].

How is it diagnosed

A doctor may determine a diagnosis of depression based on several approaches^[6]:

Physical exam: Your doctor may do a physical exam and ask questions about your health. In some cases, depression may be linked to an underlying physical health problem^[6].

Lab tests: For example, your doctor may do a blood test called a complete blood count or test your thyroid to make sure it is functioning properly^[6].

Psychiatric evaluation: Your mental health professional asks about your symptoms, thoughts, feelings and behavior patterns. You may be asked to fill out a questionnaire to help answer these questions^[6].

DSM-5: Your mental health professional may use the criteria for depression listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association^[6].

History of a manic or hypomanic episode must be ruled out to make a diagnosis of major depressive disorder^[2].

Treatment options

Depression is a common, serious, and treatable condition^[1]. Treatment during the acute phase of a major depressive episode aims to help the patient reach a remission state and eventually return to their baseline level of functioning^[10].

Mild depression

If you have less severe (mild) depression, the following treatments may be recommended^[8]:

Watchful waiting: If a doctor diagnoses you with mild depression, they may suggest waiting a short time to see if it gets better by itself. In this case, you will be seen again after 2 to 4 weeks to monitor your progress^[8].

Guided self-help: You may try guided self-help to see if it can help with your depression. You will usually have 6 to 8 sessions where you work through a workbook or online course, with support from a therapist. Guided self-help for depression is usually based on the principles of cognitive behavioural therapy (CBT), which is a type of therapy that can help you manage your problems by changing the way you think and behave^[8].

Exercise: There is evidence that exercise can help depression, and it is one of the main treatments for mild depression^[8].

Moderate to severe depression

If you have more severe depression, which includes moderate or severe depression, the following treatments may be recommended^[8]:

Antidepressants: Antidepressants are medicines that treat the symptoms of depression. There are many different types of antidepressant. They have to be prescribed by a doctor, usually for depression that is moderate or severe. Second-generation antidepressants (such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, serotonin modulators, and atypical antidepressants) are first-line therapy for depression^[11].

Psychotherapy: In the primary care setting, antidepressant medication and psychotherapy should be offered for the treatment of depression^[11]. Several types of talking therapies are available for depression, including cognitive behavioural therapy and counseling^[8].

Combination therapy: A doctor may recommend that you take a course of antidepressants plus talking therapy, particularly if your depression is quite severe. A combination of an antidepressant and CBT usually works better than having just one of these treatments. The combination of medication and psychotherapy is preferred for severe depression^[8].

Electroconvulsive therapy: Electroconvulsive therapy is the most effective somatic therapy for depression^[10].

Treatment history, comorbidities, costs, and risk of adverse effects should be considered when choosing an antidepressant medication^[11]. Choice of medication should be guided by shared decision-making, with consideration of prior treatment and response, existing health conditions, costs, and risk of adverse effects^[11].

Mental health teams

If you have severe depression, you may be referred to a mental health team made up of psychologists, psychiatrists, specialist nurses and occupational therapists. These teams often provide intensive specialist talking treatments as well as prescribed medicine^[8].

Living with major depression

There are some key steps you can take to lift your mood and help your recovery from depression^[13].

Taking your medicine

It is very important to take your antidepressants as prescribed, even if you start to feel better. If you stop taking them too soon, your depression could return. Stopping suddenly can also increase the risk of withdrawal side effects^[13].

Although many patients use antidepressants indefinitely, few studies have examined safety and effectiveness beyond two years. There is an increased risk of relapse or recurrence of depressive symptoms when an antidepressant is discontinued, compared with continued use. Gradually tapering the dosage while concurrently providing cognitive behavior therapy can decrease this risk^[11].

Diet and exercise

Exercise and a healthy diet can make a significant difference to how quickly you recover from depression. Both will improve your general health as well^[13].

A healthy diet can help lift your mood. In fact, eating healthily seems to be just as important for maintaining your mental health as it is for preventing physical health problems. Being physically active can lift your mood, reduce stress and anxiety, encourage the release of endorphins (your body’s feel-good chemicals) and improve self-esteem. Exercising may also be a good distraction from negative thoughts, and it can improve social interaction^[13].

Mindfulness

Paying more attention to the present moment – to your own thoughts and feelings, and to the world around you – can improve your mental wellbeing. Some people call this awareness “mindfulness,” and you can take steps to develop it in your own life^[13].

Talking about it

Sharing a problem with someone else or with a group can give you support and an insight into your own depression. If you do not feel comfortable about discussing your mental health and sharing your distress with others, writing about how you feel or expressing your emotions through poetry or art are other ways to help your mood^[13].

Smoking, drugs and alcohol

If you have depression it may be tempting to smoke or drink to make you feel better. Cigarettes and alcohol may seem to help at first, but they make things worse in the long run. Be extra cautious with cannabis. You might think it is harmless, but research has shown a strong link between cannabis use and mental illness, including depression^[13].

Work and finances

If your depression is caused by working too much or if it is affecting your ability to do your job, you may need time off to recover. It is important to avoid too much stress, and this includes work-related stress^[13].

Meaningful activities

Find small ways to be of service to others. Find personal meaning by serving something larger than yourself. Remember service does not have to be big to count^[14]. Schedule pleasant activities or events and do not wait for yourself to be “in the mood”^[14].

Socializing

When you are depressed, it is common to withdraw and isolate yourself. However, this is not a good time to be closed off from your loved ones. Try to make plans with friends or family and follow through with them. Another way to socialize is by volunteering. This is a great opportunity to serve others, reduce stress, and increase positive feelings^[15].