People often feel sad, blue, or ‘depressed’ from time to time. These feelings are usually short lived, and do not interfere with daily life. Major Depressive Disorder, on the other hand, is a serious medical condition that affects the mind and body impacting more than 350 million people around the world. It is an illness in the same way that diabetes, heart disease and cancer are and is not, as many people believe, a bad attitude or ‘all in the head’.
The primary difference between feeling sad, and Major Depressive Disorder, is time and duration. If the following symptoms are persistent and last longer than two weeks, start to interfere with daily life, and are negatively impacting relationships, it may be Major Depressive Disorder and time to talk to a doctor.
One in five people will suffer from depression during their lifetime, and it is the leading cause of disability worldwide. The good news is that depression is treatable. While we have a long way to go in understanding the brain, there are effective therapies and we are learning more and more every day to provide effective treatment to those in need.
Types of Depression / Symptoms
Major Depression (Also known as Major Depressive Disorder, Chronic Major Depression or Unipolar Depression)
Major Depression is manifested by a combination of symptoms that interferes with the ability to work, study, sleep, eat and enjoy once pleasurable activities. A Major Depressive episode may occur only once; but more commonly, several episodes may occur in a lifetime. Chronic Major Depression may require a person to continue treatment and monitor lifestyle habits on an ongoing basis. This disorder is characterized by the presence of the majority of these symptoms:
Symptoms of Major Depression include:
- Persistent sad, anxious, or “empty” mood most of the day, nearly every day, as indicated by subjective report or observation of others (e.g., appears tearful). In children and adolescents, this may be characterized as an irritable mood.
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness, helplessness
- Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
- Decreased energy, fatigue, being “slowed down”
- Difficulty concentrating, remembering, making decisions
- Trouble sleeping, early-morning awakening, or oversleeping
- Appetite and/or weight changes
- Thoughts of death or suicide, or suicide attempts
- Restlessness, irritability, and/or angry outbursts
- Persistent physical symptoms, such as headaches, digestive disorders, and chronic pain, which do not respond to routine treatment
Dysthymia is characterized by an overwhelming yet chronic state of depression, exhibited by a depressed mood for most of the days, for more days than not, for at least 2 years. (In children and adolescents, mood can be irritable and duration must be at least 1 year.) The person who suffers from this disorder must not have gone for more than 2 months without experiencing two or more of the following symptoms:
Symptoms of Dysthymia
- Appetite and/or weight changes
- Trouble sleeping, early-morning awakening, or oversleeping
- Decreased energy, fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
In addition, no Major Depressive Episode has been present during the first two years (or one year in children and adolescents) and there has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder. Further, the symptoms cannot be due to the direct physiological effects of use or abuse of a substance such as alcohol, drugs or medication or general medical condition. The symptoms must also cause significant distress or impairment in social, occupational, educational, or other important areas of functioning.
Another type of depressive illness is bipolar disorder (in the past described as manic-depressive illness). Bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression), often with periods of normal mood in between. Sometimes the mood switches are dramatic and rapid, but usually they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of depression. When in the manic cycle, the individual may be overactive, over-talkative, and have a great deal of energy.
Bipolar disorder is characterized by more than one bipolar episode. There are four basic types of bipolar disorder.
1. Bipolar I Disorder
The primary symptom presentation is manic, or rapid (daily) cycling episodes of mania and depression that last at least seven days. Manic episodes may be so severe that the individual may require hospitalization. Depressive episodes typically last at least two weeks.
2. Bipolar II Disorder
The primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause market impairment in social or occupational functioning or need for hospitalization, but are sufficient to be observable by others).
3. Bipolar Disorder Not Otherwise Specified
Symptoms of the disorder exist, but do not meet diagnostic criteria for either Bipolar I or II. However symptoms are well out of normal range for the individual.
4. Cyclothymic Disorder
A chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder but have been present for at least two years.
Mania often affects thinking, judgment, and social behavior in ways that cause serious problems. For example, the individual in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees and unsafe sex. Mania, left untreated, may worsen to a psychotic state. Manic episodes are characterized by:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary)).
B. During the period of mood disturbance, three or more of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:
Symptoms of Mania
- Abnormal or excessive elation
- Unusual irritability
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
- Grandiose notions or increased self-esteem
- Increased talking or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained purchasing sprees, sexual indiscretions, or foolish business investments).
- Markedly increased energy
- Poor judgment
- Inappropriate social behavior
- Distractibility (i.e., attention easily drawn to unimportant or irrelevant external stimuli)
Depressive episodes are characterized by symptoms described above for Major Depressive Episode.
Persistent Depressive Disorder
A depression that lasts over 2 years, involving symptoms that come and go in severity. The key is that the symptoms must be present at least two years
Seasonal Affective Disorder (SAD)
A depression starting in the winter months, usually stemming from low natural sunlight and often lifting in the summer months. Sad may be effectively treated with light therapy (Full Spectrum Lighting), but about half do not respond to treatment and benefit from a combination of therapy and medication.
A severe depression where the person has some form of psychosis along with other symptoms. This psychosis can include having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others cannot hear or see (hallucinations).
This depression occurs right after giving birth. It is much more than the “baby blues” that many women experience after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. It seriously interferes with the woman’s daily activities. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.
Substance Induced Mood Disorder (abuse or dependence)
Substance-Induced Mood Disorder is a common depressive illness of clients in substance abuse treatment. It is defined in DSM-V-TR as “a prominent and persistent disturbance of mood…that is judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or somatic treatment for depression, or toxin exposure). The mood can manifest as manic (expansive, grandiose, irritable), depressed, or a mixture of mania and depression.
Generally, substance-induced mood disorders will only present either during intoxication from the substance or on withdrawal from the substance and therefore do not have as lengthy a course as other depressive illnesses. However, substance use disorders also frequently co-occur with other depressive disorders. Research has revealed that people with alcoholism are almost twice as likely as those without alcoholism to also suffer from major depression. In addition, more than half of people with bipolar disorder type I (with severe mania) have a co-occurring substance use disorder.
Men are more likely than women to report alcohol and drug abuse or dependence in their lifetime; however, there is debate among researchers as to whether substance use is a “symptom” of underlying depression, or a co-occurring condition that more commonly develops in men. Nevertheless, a substance use can mask depression, making it harder to recognize depression as a separate illness that needs treatment.
When a disease or disorder occurs at the same time as another, but is unrelated to it, it is considered to be comorbid. Among those suffering with depression, 92% also reported meeting the criteria for at least one additional mental illness. The most common mental illnesses are:
- Behavioral disorders (ADD/ADHD, Conduct disorder)
- Substance abuse disorders
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. 5th edition. Washington, DC: American Psychiatric Association.
Depression and Suicide in Children and Adolescents. Surgeon General’s Health Report.