Major depression
- Reviewed by Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
What is major depression?
In major depression, the most prominent symptom is a severe and persistent low mood, profound sadness, or a sense of despair. The mood can sometimes appear as irritability. Or the person suffering major depression may not be able to enjoy activities that are usually enjoyable.
Major depression is more than just a passing blue mood, a "bad day," or temporary sadness. The symptoms of major depression are defined as lasting at least two weeks but usually they go on much longer — months or even years.
A variety of symptoms usually accompany the low mood, and the symptoms can vary significantly among different people.
Many people with depression also have anxiety. They may worry more than average about their physical health. They may have excessive conflict in their relationships and may function poorly at work. Sexual functioning may be a problem. People with depression are at more risk for abusing alcohol or other substances.
Depression probably involves changes in the areas of the brain that control mood. Nerve cells may be functioning poorly in certain regions of the brain. Communication between nerve cells or nerve circuits can make it harder for a person to regulate mood. Hormone changes may also negatively affect mood. An individual's life experience affects these biological processes. And genetic makeup influences how vulnerable a person is to getting this illness.
An episode of depression can be triggered by a stressful life event. But in many cases, depression does not appear to be related to a specific event.
A major depressive episode may occur just once in a person's life or may return repeatedly. People who have many episodes of major depression may also have periods of persistent but milder depressed mood.
During a major depressive episode, thinking can get out of step with reality. The person has "psychotic symptoms" such as false beliefs (delusions) or false perceptions (hallucinations).
Some people who have episodes of major depression also have episodes of relatively high energy or irritability. They may sleep far less than normal, and may dream up grand plans that could never be carried out. The severe form of this is called "mania" or a manic episode. Psychotic symptoms also occur in mania. If a person has milder symptoms of mania and does not lose touch with reality, it is called "hypomania" or a hypomanic episode.
A major depressive episode may occur within the first two to three months after giving birth to a baby. In that case, it may be called major depressive disorder with peripartum onset. Most people refer to it as postpartum depression.
Depression that occurs mainly during the winter months is usually called seasonal affective disorder, or SAD. It also may be called major depressive disorder with seasonal pattern.
Episodes of depression can occur at any age. Depression is diagnosed in women twice as often as in men. People who have a family member with major depression are more likely to develop depression or drinking problems.
Symptoms of major depression
A depressed person may gain or lose weight, eat more or less than usual, have difficulty concentrating, and have trouble sleeping or sleep more than usual. He or she may feel tired and have no energy for work or play. Small burdens or obstacles may appear impossible to manage. The person can appear slowed down or agitated and restless. The symptoms can be quite noticeable to others.
A particularly painful symptom of this illness is an unshakable feeling of worthlessness and guilt. The person may feel guilty about a specific life experience or may feel general guilt not related to anything in particular.
If pain and self-criticism become great enough, they can lead to feelings of hopelessness, self-destructive behavior, or thoughts of death and suicide. The vast majority of people who suffer severe depression do not attempt or commit suicide, but they are more likely to do so than people who are not depressed.
The thoughts of people with major depression are often colored by their dark mood. For example, pessimistic ideas may be out of proportion with the reality of the situation. Sometimes, the depressed thinking is distorted enough to be called "psychotic"; that is, the person has great difficulty recognizing reality. Sometimes, depressed people develop delusions (false beliefs) or hallucinations (false perceptions).
Symptoms of major depression include:
- distinctly depressed or irritable mood
- loss of interest or pleasure
- decreased or increased weight or appetite
- decreased or increased sleep
- appearing slowed or agitated
- fatigue and loss of energy
- feeling worthless or guilty
- poor concentration or indecisiveness
- thoughts of death, suicide attempts or plans.
Diagnosing major depression
A primary care physician or a mental health professional usually can diagnose depression by asking questions about medical history and symptoms. By definition, major depression is diagnosed when a person has many of the symptoms listed above for at least two weeks.
Many people with depression do not seek evaluation or treatment because of society's attitudes about depression. The person may feel the depression is his or her fault or may worry about what others will think. Also, the depression itself may distort a person's ability to recognize the problem. Therefore family members or friends may need to encourage the depression sufferer to seek help.
There are no specific tests for depression. However, it is important to be evaluated by a primary care physician to make sure symptoms are not being caused by a medical condition or medication.
Expected duration of major depression
On average, untreated episodes last several months. However, episodes of major depression can last any length of time. And symptoms can vary in intensity during an episode.
If depression is not treated, it can become chronic (long-lasting). Treatment can shorten the length and severity of a depressive episode.
Preventing major depression
There is no way to prevent major depression, but detecting it early can help. Treatment can both reduce symptoms and help to prevent the illness from returning.
Treating major depression
The most helpful treatment is a combination of psychotherapy and medication. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed first. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). In general, they are fairly easy to take and relatively safe compared with previous generations of antidepressants. One of the more common side effects is decreased sexual pleasure and delayed orgasm.
Other effective antidepressants include bupropion (Wellbutrin), venlafaxine (Effexor), mirtazapine (Remeron), and duloxetine (Cymbalta).
It often takes two to six weeks from the start of medication to see improvement. It may take several trials to find the medication that works best. Once the right medication is found, it may take up to a few months to find a proper dose and for the full positive effect to be seen.
Sometimes, two different antidepressants are used together. Or a mood stabilizer, such as lithium (sold under several brand names) or valproic acid (Depakene, Depakote), is added. If psychotic symptoms are present, a doctor may prescribe a second medication.
A number of psychotherapy techniques have been demonstrated to be helpful, depending on the causes of the depression, the availability of family and other social support, and personal style and preference. A technique called cognitive behavioral therapy is designed to help a depressed person recognize negative thinking and teaches techniques for controlling symptoms. Psychodynamic, insight-oriented, or interpersonal psychotherapy can help depressed people to sort out conflicts in important relationships or explore the history behind symptoms.
If you suffer from depression, you will benefit from educating yourself about the illness. You could also make use of support that may be available in your community.
Options for severe or persistent depression despite the usual medications include electroconvulsive therapy (ECT), ketamine, and transcranial medical stimulation.
Antidepressants and suicide risk
The FDA requires antidepressant manufacturers to include a so-called "black box warning" on their product labeling. The warning is intended to address the concern that — only for children, adolescents, and young adults — antidepressants may increase the risk of suicide. This problem has remained a focus of research, but the evidence remains hard to interpret.
Many experts worry that this warning has had a chilling effect on antidepressant treatment. The danger is that doctors and patients both could shy away from a helpful intervention. When depression goes untreated, the risk of suicide goes up.
A small number of young people taking these medications probably do have an unusual reaction and end up feeling much worse rather than better. Furthermore, any medication taken to affect mood can have an unexpected negative effect.
Therefore, it is always important to monitor treatment closely. No matter what age you are or what treatment you're getting, report any troubling symptoms or worsening mood to your doctor immediately.
When to call a professional
Depression is a painful and potentially dangerous illness, so you should contact a health care professional if you have any suspicion that you or a loved one is depressed.
Prognosis
Treatment of depression has become quite sophisticated and effective. The prognosis with treatment is excellent. The intensity of symptoms and the frequency of episodes often are significantly reduced. Many people recover completely.
When treatment is successful, it is important to stay in close touch with your doctor or therapist, because maintenance treatment is often required to prevent depression from returning.
Additional info
National Institute of Mental Health
https://www.nimh.nih.gov/
American Psychiatric Association
https://www.psychiatry.org
American Psychological Association
https://www.apa.org/
About the Reviewer
Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
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