Are You Simply Sad or Do You Have Major Depressive Disorder?

Do you struggle to get out of bed most mornings? Is just the thought of getting dressed exhausting? Is it less and less fun to spend time with friends and family? Do you find yourself eating a lot more or a lot less than usual?

Many people think that being depressed simply means feeling really, really sad. Yet you don’t have to be teary to be depressed. All of the behaviors above — and a myriad of others that affect how you think, feel, behave, and express yourself — can be signs of depression.

In fact, depression is one the most common illnesses worldwide, according to the World Health Organization. (1) In the United States alone it affects an estimated 17.3 million adults ages 18 and older (8.7 percent of women and 5.3 percent of men) as well as an estimated 3.2 million adolescents ages 12 to 17 (13.3 percent), per the National Institute of Mental Health (NIMH). (2)

You’ve probably heard the word “depression” tossed around to describe normal everyday dips in mood, things like “This haircut made me so depressed” or “That movie was so sad, I’m depressed.” But when you are actually depressed, “You’re not just blue or down in the dumps,” says clinical psychologist Lorna Gale Cheifetz, PsyD. “You’re really not functioning.”

In fact, to be diagnosed with major depressive disorder — sometimes called clinical depression or simply depression, or by its abbreviation, MDD — you have to experience several distinct symptoms for most of the day, nearly every day, for at least two weeks.

One of those symptoms needs to be persistent feelings of sadness or emptiness, or a loss of interest in activities you used to enjoy, such as work, hobbies, seeing friends — even food and sex.

According to the American Psychiatric Association’s current Diagnostic and Statistical Manual of Mental Disorders (DSM-5), you also need to experience at least four of the following symptoms (or three if you have both of the symptoms above):

• Significant changes in appetite — weight loss or gain not related to dieting
• Trouble sleeping (insomnia) or sleeping too much (hypersomnia)
• Increased restlessness (called psychomotor agitation) or the opposite, moving more slowly (called psychomotor retardation)
• Fatigue, tiredness, or loss of energy, making even simple tasks, such as dressing or washing, difficult
• Feeling worthless or inappropriately guilty, such as constantly thinking about past mistakes
• Difficulty thinking clearly, concentrating, or making decisions
• Recurrent thoughts of death or suicide (without or without a specific plan), or a suicide attempt

It’s important to note that to count toward a diagnosis of major depressive disorder, a symptom must cause significant distress or make everyday tasks much harder than usual. So, for example, if you normally have trouble falling asleep, insomnia wouldn’t count as a symptom of major depression for you.

When Is It Not Major Depressive Disorder?

If you have some of the symptoms above, but not enough of them, or they’re not severe enough to meet the criteria for MDD, you might have persistent depressive disorder (PDD), the DSM-5’s new name for what was previously called dysthymia.

PDD symptoms are similar to MDD symptoms — sleep problems, low energy, low self-esteem, difficulty concentrating, poor appetite, and feelings of hopelessness — but they’re milder and they’re chronic: You can generally function, just not at your best.

To meet the criteria for PDD, your mood needs to be low and you must have at least two other symptoms for two years or more.

It’s also possible to have something called “double depression,” in which PDD evolves into MDD (typically provoked by a triggering event, such as losing a job or failing to achieve an important goal) then reverts back to PDD. Although not well known, double depression affects 75 percent of people with PDD at some point, according to the National Alliance on Mental Illness. (3)

You can even feel depressed and not have a mood disorder at all. That’s because symptoms of many other medical conditions, including anemia, thyroid problems, Lyme disease, Parkinson’s disease, and pancreatic cancer, can masquerade as depression. (4)

Making matters more confusing, your medication could be to blame. A University of Illinois at Chicago College of Pharmacy study, published in June 2018 in The Journal of the American Medical Association, estimated that 33 percent of U.S. adults may be using one or more prescription drugs that can cause side effects that mimic depression, including thoughts of suicide. (5) These include oral contraceptives, as well as certain treatments for high blood pressure, high cholesterol, acid reflux, and severe acne.

“Patients and healthcare providers need to be aware of the risk of depression that comes with all kinds of common prescription drugs — many of which are also available over the counter,” notes Dima Mazen Qato, PharmD, PhD, assistant professor in the Department of Pharmacy Systems, Outcomes, and Policy at The University of Illinois at Chicago and lead author of the study.

“Many may be surprised to learn that their medication, despite having nothing to do with mood or anxiety or any other condition normally associated with depression, can increase their risk of experiencing depressive symptoms, and may lead to a depression diagnosis."

There’s broad agreement among mental health professionals and researchers that depression is primarily caused by three kinds of factors that interact to varying degrees in each patient: biological (including your genes, your hormones, and your physical health), psychological (such as your coping skills and how you view yourself), and social (like early life events or prolonged stress at work or home).

Recent research also points to the importance of the health of the gut’s microbiome, the “good” bacteria the keep your digestive tract functioning at its best. A healthy microbiome appears to play an essential role in the release of hormones and mood-lifting brain chemicals, according to an article published February 2019 in Science magazine. (6)

Major depression is very treatable, especially when the approach is tailored to an individual’s body and lifestyle. Yet approximately 35 percent of adults and 60 percent of adolescents who have it don’t receive any treatment. (2)

This is worrisome given that depression raises the risk of many other illnesses, including heart disease, diabetes, stroke, and Alzheimer’s disease, and has been linked to substance abuse. (7,8)

Depression also increases the risk of suicide, the 10th leading cause of death in the United States, according to the NIMH. (9)

Reasons for not getting treatment vary. “A lot of people suffer in silence because we don’t yet live in a culture where it’s easy to talk authentically about it,” says psychotherapist Hilary Jacobs Hendel, a licensed clinical social worker and author of It’s Not Always Depression: Working the Change Triangle to Listen to the Body, Discover Core Emotions, and Connect to Your Authentic Self. “People feel a lot of shame and guilt.”

Another reason is that depression encourages the belief that nothing could ever be of help. As journalist Susan Cheng explained in an essay she wrote about her depression, “Sometimes you fight back, but most days you just sit there in quiet resignation, trying your best to breathe. And because the illness is a part of you, engrained so deeply in your being, you start to believe that this is just how everyone must feel.” (10)

A key barrier is also cost of care. Having inadequate insurance or no coverage can make the cost of prescription drugs and psychotherapy prohibitive. Poverty doubles the likelihood that a person may experience major depression, yet that same factor makes it harder to access treatment. (11) Fortunately, a few low-cost options exist, including:

• Teaching hospitals and universities with training programs in psychiatry and psychology, which often offer low-cost psychotherapy provided by trainees supervised by senior staff
• The Medicine Assistance Tool from the Pharmaceutical Research and Manufacturers of America, which connects to a database of hundreds of public and private programs that provide eligible patients with prescription drugs at a discount or for free
• Retailers, including Walmart, Walgreens, and Rite Aid, selling several frequently prescribed generic drugs for as little as $4 (12)

As with many illnesses, the earlier treatment for depression begins, the more effective it is likely to be at alleviating symptoms and reducing the odds of a recurrence. “The sooner you can internalize some of what you learn, the longer you can carry that knowledge with you to help you stay healthy,” says Carol Landau, PhD, a clinical professor of psychiatry and medicine at the Alpert Medical School of Brown University in Providence, Rhode Island.

After having a good medical workup to rule out any underlying causes, a person diagnosed with major depression can be treated a number of ways. The most frequently used approaches are medication, thought to relieve symptoms by reversing imbalances in brain chemistry; psychotherapy aimed at altering patterns that negatively affect mood; or a combination of the two.

Studies suggest that typically a combination of psychotherapy and medication is more effective than either method alone. The reason isn’t clear. Perhaps medication eases symptoms so that patients are more open to psychotherapy. Or maybe psychotherapy increases the odds that patients will stick to their medication schedule. It could even be that having two clinicians, one who prescribes medication and one who provides talk therapy, enhances the treatment of both.

The approach chosen may be dictated by the severity of symptoms. Mild to moderate depression, for instance, is often treated first with psychotherapy. More severe symptoms may require medication from the start. (13)

A meta-analysis published in April 2018 in the journal The Lancet offered more insight into why medication alone isn’t necessarily the answer. After investigating the effects of 21 antidepressants in 116,477 adults across 522 clinical trials, researchers concluded, “All antidepressants were more effective than placebo,” but with the caveat that the benefits were “mostly modest.” (14)

“Antidepressants can be an effective tool to treat major depression, but this does not necessarily mean that antidepressants should always be the first line of treatment,” says Andrea Cipriani, MD, PhD, lead author of the study and a professor in the department of psychiatry at Oxford University in the United Kingdom. “Medication should always be considered alongside other options, such as psychological therapies, where these are available. Patients should be aware of the potential benefits from antidepressants and always speak to the doctors about the most suitable treatment for them individually.”

Which Types of Psychotherapy Work Best?

Psychotherapy always includes talking with a trained professional focused on helping you make positive changes in your thoughts and behaviors to ease your symptoms. But there’s some evidence that certain types may be more effective for depression than others, notes the NIMH. (15) These include:

• Cognitive behavioral therapy (CBT), a systematic approach aimed at identifying and altering negative thought patterns
• Dialectical behavioral therapy (DBT), which emphasizes psychotherapy and group classes in new skills, such as mindfulness, to help make life feel worth living
• Interpersonal therapy (IPT), which focuses on increasing happiness by improving how you interact with others
• Psychodynamic therapy, which aims to reduce the negative influence of past life events and traumas through insight into how they affect your current behavior
• Accelerated experiential dynamic psychotherapy (AEDP), which teaches patients to view depression as a defense against core emotions, including sadness, fear, anger, sexual excitement, and disgust, so that fully feeling those emotions can help restore hope and optimism

Treatment for Severe Major Depressive Disorder

When traditional treatments don’t work, psychiatrists may turn to brain stimulation therapy, the best-known options of which are: (16)

• Electroconvulsive Therapy (ECT, Also Known as Shock Treatment) Done under anesthesia, ECT involves using short electrical impulses to cause seizures that are thought to repair faulty wiring in the brain.
• Repetitive Transcranial Magnetic Stimulation (rTMS) Done while the patient is awake and alert, this uses a magnet instead of an electrical current to stimulate brain regions linked to mood.

New Treatments for MDD

Recent research has shown that ketamine, primarily used as a tranquilizer in veterinary medicine and abused as a recreational club drug called Special K, can rapidly lift people out of depression and keep even chronically suicidal patients feeling well for days, if not weeks.

Scientists testing ketamine at the University of Illinois at Chicago College of Medicine reported in a study published June 2018 in the journal Molecular Psychiatry that 66 percent of patients felt better within hours after receiving a single infusion of ketamine through an IV (intravenously). (17)

In 2019, the U.S. Food and Drug Administration (FDA) approved Spravato (esketamine), a nasal spray derived from ketamine, for people who haven’t responded to other depression treatments. Esketamine can only be administered at certified treatment centers because of the potential for abuse and addiction. (18)

Hallucinogenic mushrooms, LSD, and other psychedelics are emerging as another potential new treatment for depression

Anecdotal accounts and federally approved studies, as reported in Michael Pollan’s best-selling book on the subject, How to Change Your Mind, suggest that miniscule doses — one-twentieth to one-tenth of recreational doses — significantly lessen depression, possibly by increasing new connections in the brain. (19)

In September 2019, John Hopkins Medicine in Bethesda, Maryland, launched the Center for Psychedelic and Consciousness Research, a first-of-its-kind initiative studying compounds like psilocybin (the active ingredient in hallucinatory mushrooms) and their effect on a range of mental health problems, including treatment-resistant depression. 

Having major depression is not something you can just beat with willpower. But you can tweak your lifestyle to find some relief.

Seek out friends and family. It may not come as a surprise that loneliness increases the risk of depression. “The importance of social support is not talked about nearly enough,” says Dr. Landau.

Eat healthier, nutrient-rich foods. A growing body of research suggests that what you eat can affect your mental health. For example, a study published in October 2019 in the journal PLoS One found that symptoms of depression dropped from the “moderate” to “normal” range among a group of young adults who followed a Mediterranean-style pattern of eating for three weeks, increasing their intake of fruits, vegetables, whole grains, lean protein, unsweetened dairy, fish, nuts, seeds, and olive oil. (20)

Be more physically active. Research indicates that exercise can help prevent and treat depression. For instance, an analysis published in May 2018 in JAMA Psychiatry looked at more than 30 previous studies and concluded that resistance training (such as weight lifting or strength training) is associated with a significant reduction in depression symptoms. (21)

A Silver Lining

Al Levin, an assistant elementary school educator in St. Paul, Minnesota, was in a hopeless, dark place in the fall of 2013 when a second bout of paralyzing depression hit him. “Suddenly, I was unable to stop crying for 30 minutes at a time,” recalls the father of four, who is now in his fifties. “I could not sleep. I could not eat. I could not summon the will to do much of anything. I was in such a dire situation, I was searching the internet for which method of suicide would work best.”

That’s when he knew he needed help, which he got through a partial hospitalization program that provided not just medication and psychotherapy, but also taught him coping skills to help prevent a recurrence. These days, Levin is energized by a newfound passion: working towards minimizing or even eliminating the stigma around mental health through his podcast, The Depression Files.

“Going through major depressive episodes has changed me in positive ways,” Levin says. “I definitely had some awful stereotypes in my mind about people with mental illness. When I thought of depression, I thought of disheveled people who just didn’t want to fix themselves. I now know how debilitating it can be and how much it can impact the whole being of anyone at any time. It’s been a humbling experience, for which I am definitely grateful.”

If you or someone you know is in crisis or thinking of suicide, get help quickly:

• Call your doctor.
• Call 911 for service or go to the nearest emergency room.
• Talk to a trained counselor by calling the toll-free 24-hour National Suicide Prevention Lifeline at 800-273-TALK (8255); TTY: 800-799-4TTY (4889).
• Avoid leaving a suicidal person alone.

For more information, resources and research on depression, go to MentalHealth.gov, the National Institute of Mental Health (NIMH) website, or the National Library of Medicine’s MedlinePlus.

Favorite Organizations for MDD

American Psychiatric Association

The APA is a great resource for anyone battling MDD. You can easily locate a doctor in your area on their Find a Psychiatrist page.

National Institute of Mental Health (NIMH)

Want up-to-date information about MDD? The NIMH offers free, easy-to-read publications on various mental disorders under the Health and Education section of their website. They also offer e-books for select materials, and some are written in Spanish.

Mental Health America (MHA)

The MHA offers tons of information about various types of depression. Take their depression test to see if your symptoms indicate that you have risk factors.

Favorite Online Support Networks

24-Hour National Suicide Prevention Lifeline

Don’t take matters into your own hands. Instead, talk to trained counselors who are available 24 hours a day at the National Suicide Prevention Lifeline. Support is free and confidential. The number to call: 800-279-TALK (8255).

Anxiety and Depression Association of America (ADAA)

Sometimes, connecting with others can help you work through your bad days. If you’re looking for support, the ADAA can help. Search for a support group near you or start your own.

Favorite Advocacy Groups

MentalHealth.gov: Conversations in Your Community

Community conversation events, which take place across the country, give people a chance to learn more about mental health issues. You can help start a conversation in your own community by using the tools provided on MentalHealth.gov.

Favorite App

Catch It

Looking for ways to manage your lows? Enter some information about your current mood, and this app prompts you to look at the situation in a different way by using cognitive-behavioral techniques. The idea is to “catch it, check it, and change it.” You can even store your entries, so you can go back and look at your mood patterns.

Favorite Annual Meetings

Anxiety and Depression Association of America

This annual conference brings together more than 1,400 clinicians and researchers from around the world. The focus is to highlight improved treatments for anxiety, depression, and related disorders.

Favorite Retreat

The Meadows Treatment Center

This treatment center in Wickenburg, Arizona, offers help for patients with a variety of mental health and addiction disorders. Their clinicians and therapists specialize in treating not only the symptoms of depression but also the underlying causes. They’ve been around for more than 40 years and use a holistic approach to healing.

Additional reporting by Pamela Kaufman.