Depression is formidable, but for those who experience double depression, a term used to describe the occurrence of two separate depressive disorders, the symptoms and outlook may feel even more bleak. Though the presence of both major depressive disorder and persistent depressive disorder is impactful, double depression can be well-treated with a combination of therapy and medications.
What Is Double Depression?
While the term “double depression” isn’t typically used in a clinical setting, the phrase communicates the existence of co-occurring depressive disorders. A person with persistent depressive disorder, sometimes called dysthymia, as well as major depressive disorder is said to have “double depression” due to the way these separate conditions combine.1
Depression encompasses a group of mental health disorders that are separate and unique due to the way they emerge, the symptoms they trigger, and the duration of effects.
Some of the conditions that may trigger depressive symptoms include:2
- Major depressive disorder (MDD)
- Bipolar disorder I and bipolar II disorders
- Disruptive mood dysregulation disorder (DMDD)
- Premenstrual dysphoric disorder (PMDD)
- Depressive disorder due to substance misuse or a medical condition
- Persistent depressive disorder (PDD) (dysthymia)
Some of these conditions may overlap while others are mutually exclusive. For example, a person cannot have bipolar disorder and MDD, because bipolar disorder includes periods of major depression.2 With double depression, a person has persistent depressive disorder, which persists for at least two years, and episodes of major depression. When these disorders combine, they create a mix of chronic and acute symptoms that cause great distress.
How Is Double Depression Different From Major Depression Without Dysthymia?
The major difference between MDD on its own and MDD with persistent depressive disorder is what happens during the time between depressive episodes. Someone with MDD will have episodes that last at least two weeks. When symptoms are low, a person with MDD can report good moods, energy, and motivation, just like someone without depression.
Someone with double depression will continue to feel chronic symptoms like sadness and low motivation between major depressive episodes. In this way, the person will always experience some level of depression and may feel like they are never happy.
About three times as many people have major depression than persistent depressive disorder each year, so MDD is a much more common condition.2 About 25% of people with MDD will note some duration of dysthymic symptoms during their lifetime.1
Signs of Double Depression
With double depression, many people show the typical signs of depression, like low mood and low energy, but due to the unique nature of double depression, the expression could deviate. Some people could show symptoms like irritability and even physical health symptoms that seem to have little to do with depression.
A person displaying the usual signs of depression may seem down, sad, and angry. They may no longer be interested in spending time with friends, going to fun places, or engaging in any activities that previously brought them pleasure. When they speak, they could be overly negative and pessimistic, speaking only about problems and annoyances.2 A person with double depression could show drastic changes to their weight, diet, sleep schedule, and exercise routine. This shift could occur all at once or gradually over time.
The age of the person with double depression could also influence the condition’s signs:3
- Younger adults: More likely to show irritability, weight gain, and oversleep. They could complain of anxiety disorders or try to conceal their depression with substances like alcohol or other drugs.
- Middle-aged adults: Complain of digestive issues linked to depression, like constipation or diarrhea. They could have lower libido, wake up in the middle of the night or too early in the morning.
- Older adults: Feel numb instead of sad or depressed. When depression is severe enough, it could impact their memory and thinking abilities.
Due to the chronic nature of double depression, it would be rare for an adolescent to have a persistent depressive disorder diagnosis, but teens do have depression. They could show signs like low frustration tolerance, restlessness, and low self-esteem linked to their depression.
Symptoms of Double Depression
In terms of diagnosis, the symptoms of double depression will involve separate diagnostic criteria for each disorder. When a person meets the standards for both MDD and PDD, they will have double depression.
The symptoms of MDD include:2
- A depressed or irritable mood most of the day on most days
- Less interest or pleasure in activities that were previously seen as fun and engaging
- Significant and unintended weight changes or appetite changes
- Sleeping too much or too little
- Feeling very sped up or slowed down behaviorally
- Low energy and motivation
- Feeling very guilty or worthless
- Limited about to think clearly, focus, and concentrate
- Thinking about death, dying, and suicide
A person will need to display five or more of these symptoms during a two-week period to receive the MDD diagnosis.
The symptoms of PDD include:2
- Low mood more often than not over a two-year period
- Low appetite or overeating
- Too little or too much sleep
- Fatigue
- Low self-esteem
- Poor decision-making skills
- Feeling hopeless
The individual will need only two or more symptoms to meet the criteria for PDD, but as mentioned, the duration of symptoms is the most critical element of the condition. When enough symptoms for MDD and PDD are present, the person can be diagnosed with double depression.
Causes & Triggers of Double Depression
A variety of causes and risk factors contribute to the formation and expression of depressive disorders like double depression.
Common causes of double depression include:4
- Physiological brain differences: Some people may have differences in the structure or functioning of their brain. These differences could make depression more likely.
- Hormonal changes: The way the body balances hormones could cause depressive symptoms, which is why teens and women who have recently had children experience increased depressive symptoms.
- Heredity causes: People with close family members who have depression may have depression themselves. This connection leads to depression being an inheritable feature.
Depression risk factors include:4
- Traumatic or overly stressful life events
- Having a history of other mental health conditions
- Abuse of or addiction to alcohol or other drugs
- Chronic physical health conditions like cancer, pain, or heart disease
- Having a chaotic or unstable childhood
- Lack of parental support
Treatment of Double Depression
Treatment of double depression involves a two-prong approach that utilizes a combination of mental health psychotherapy and one or more medications to address and relieve the symptoms of each condition. People who incorporate healthy lifestyle changes may complement the benefits of professional treatment options.
Therapy
In therapy, a psychotherapist will utilize various techniques and strategies to combat depression by helping the individual create a sense of control and well-being. Therapy is available in numerous settings like schools, doctors’ offices, community mental health centers, hospitals, and private practice locations across the country.
The benefits of therapy for depression include:5
- Helping the person become aware of their unhealthy thinking and behavior patterns
- Teaching new ways to cope
- Planning ways to establish and maintain safety
- Offering skills and techniques to adjust their unwanted habits
Common Type of Therapies
The type of therapy used for an individual will depend on their symptoms and struggles, as well as the therapist’s experience and training.
Effective therapies for double depression are:3,7,8
- Cognitive-behavioral therapy (CBT): Examines thoughts, feelings, and behaviors to limit shift thoughts and create healthy actions
- Interpersonal therapy (IPT): A therapy style grounded in the idea that having healthy relationships will push back on depressive disorders
- Problem-solving therapy (PST): Aims to teach clients new ways to identify and resolve problems, ratchet than allowing them to grow out of control
- Acceptance and commitment therapy (ACT): A style of therapy that helps people find acceptance of some issues and discover commitment towards change other problems
One particular variation of CBT, called cognitive behavioral analysis system of psychotherapy (CBASP), is designed specifically for people with chronic depression. CBASP helps by challenging the client’s damaging perceptions and behaviors and searching for places where changed actions could have resulted in different outcomes.1
Intended Treatment Outcome & Timeline
When people have MDD only, about 40% will see improvement in three months while 80% will see improvement within one year. Unfortunately, with the addition of PDD, people with double depression are much less likely to see their symptoms resolve in a short amount of time.2 Instead, people with double depression typically see a need for long-term therapy as a way to manage symptoms.
It seems that one of the biggest influences on double depression is the patient getting the treatment form and style they want. Research suggests that an easy way to improve outcomes is when providers offer the type of therapy preferred by the individual.1
Lifestyle Changes
Professional therapies are invaluable, but what a person does in between appointments can increase the effectiveness of sessions. By engaging in positive lifestyle changes, an individual can take additional steps towards happiness and fulfillment.
Lifestyle changes that combat double depression include:6
- Exercise: Walking, swimming, weightlifting, and so many other forms of exercise promote happiness and reduce depression. By starting slowly and investing in a long-term plan, people can help regulate their moods with physical activity.
- Addressing diet and sleep: Just like with exercise, the foods people eat and the rest they get can push back against depression. Reduce sugar, increase healthy foods, and devote enough time to sleep to begin seeing the wanted results.
- Connecting with others: Double depression may make spending time socializing with friends, family, and coworkers seem like a chore, but the positives of relationships far outweigh the risks
- Reducing the unhealthy coping skills: When people are depressed, they can desperately seek ways to feel better quickly. For many of these people, alcohol, drugs, shopping, sex, and other obsessive behaviors become appealing. These options only bring short-term relief and long-term problems.
Medication
Many people choose to use medications, either alone or in combination with therapy, as a way to reduce symptoms linked to double depression. Available prescribers, like primary care doctors, psychiatrists, and nurse practitioners, will discuss the potential benefits and risks of any medication recommended.
Common groups of medications for depression are:4
- Selective serotonin reuptake inhibitors (SSRIs): Drugs that help to increase the amount of serotonin available in the brain like citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).
- Serotonin-norepinephrine reuptake inhibitors (SNRIs): Medications that include duloxetine (Cymbalta), venlafaxine (Effexor), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima). These increase both serotonin and norepinephrine in the brain.
- Atypical antidepressants: Mirtazapine (Remeron), bupropion (Wellbutrin), trazodone (Desyrel) are drugs that do not operate in the body like other antidepressants and interact with dopamine in the system.
- Tricyclic antidepressants: Drugs like amitriptyline, clomipramine (Anafranil, doxepin, imipramine (Tofranil), nortriptyline (Pamelor) are effective but may trigger more side effects.
- Monoamine oxidase inhibitors (MAOIs): Older antidepressants that force a strict diet to avoid side effectsphenelzine (Nardil), selegiline (Emsam), and tranylcypromine (Parnate).
Is Double Depression More Difficult to Treat?
As double depression is the emergence of both major depressive and persistent depressive disorders, the treatment must focus on addressing and resolving each of these conditions. The presence of double depression is more difficult to treat than either condition separately.
Managing symptoms, moving past pessimism, and promoting happiness will be a longer process for those with double depression than those with MDD alone. Second, people with double depression are more likely to have a symptom relapse. Among people who respond well to double depression treatment, half will see a return of symptoms within two years, indicating that people with double depression may need ongoing maintenance therapy.1
How to Get Help For Double Depression
In an effort to make mental health treatment available and accessible, providers, insurance companies, and other organizations have removed barriers like referrals and other limits. If a person wants help for double depression, they only have to reach out for treatment.
Some simple ways to access mental health care involve:
- Contact the local mental health agency
- Call the number on the back of one’s insurance card
- Ask the primary care doctor
- Complete a simple online search
- Search for a therapist on an online directory
- Talk to a trusted support for a referral
How to Get Help For a Loved One
Due to issues with privacy and consent to treatment, a person cannot simply sign a loved one up for mental health care. A great strategy is to compile a list of available service providers who treat double depression as well as the types of care they provide. One can also offer to attend the intake appointment with their loved one or to provide transportation as needed, since the commute to and from services can present challenges.
Perhaps most of all, a loved one can help by gently and consistently noting the potential benefits of professional treatments and the risks of not taking advantage of treatment.
Double Depression Statistics
The available numbers linked to double depression paint the picture of a challenging mental health disorder.
The statistics on double depression show:1,2
- More than 75% of people with dysthymic disorder will experience double depression
- 25% of people with major depressive disorder will have periods of double depression
- Only between 25% to 35% of people with chronic depression note symptom remission to their first antidepressant medication
- Major depressive disorder is about three times more common than persistent depressive disorder
- About 12% of people with chronic depression have not recovered after five years of treatment
7 Ways to Cope With Double Depression
Ways to cope with double depression include identifying the depression, communicating your experience, confronting your negative thoughts, shifting your negative behaviors, focusing on health, finding fulfilment, and seeking professional help.
1. Identifying the Depression
Some people spend so much time trying to escape or avoid their own thoughts, feelings, and behaviors that they do not even realize they are depressed. Spend some time each day thinking about your life while being sure to attend to issues like energy levels, mood, motivation, and views of the future. If something seems undesirable or dangerous, take quick action.
2. Communicating Your Experience
Starting a conversation with a loved one about depression and other mental health concerns can be complicated and uncomfortable, but doing so can trigger tremendous benefits. Always begin by communicating with your most trusted resource and expand the conversation from there. Communicating your experience can also help relieve the burden of feeling alone.
3. Confronting Your Negative Thoughts
In depression, negative thoughts seem like the norm. They find the worst of every situation while minimizing any positive qualities or experiences you may have. The more that these distorted views are allowed to exist, the more power they will have. Start paying attention to your thoughts and challenge the incorrect information your depression is contributing. Remember, these perspectives are not yours. They are your depression’s opinions.
4. Shifting Your Negative Behaviors
Just as you must address your unhealthy thoughts, you have to address your unhealthy behaviors. Once depression takes hold, it will manipulate you into engaging only in behaviors that make symptoms worse, instead of better. To reduce this trend, you must consider the people, places, and things that are best for you and actively seek them out. Engage in the activities you love with the people you care about to gain control of your behaviors.
5. Focusing on the Physical Health
As physical health improves, mental health will follow, so placing an increased value on physical health can result in tremendously positive mental health impacts. Beware, though, as physical health changes may face some internal resistance. You don’t have to change all facets of your physical health at once, but inspect your diet, exercise, and sleep habits. Pick one or two elements to address and form a plan.
6. Finding a Level of Fulfillment
Being fulfilled may feel foreign as depression has a way of wiping away any sense of accomplishment. It remains a worthwhile goal, though. So much of depression is focused on yourself that you begin losing sight of others. Many people find a strong sense of purpose by giving back to the community or people who are struggling with their own issues. Something powerful happens when you give to others, and this fulfillment could push depression out of the way.
7. Seeking Professional Treatment
The finest lifestyle changes and the most valuable coping skills do well to support the battle against depression, but making the decision to start professional therapy or medication services is the best coping skill someone with double depression could make. Starting treatment is important, but sticking to it long-term is even more valuable, so do not get scared or frustrated if symptoms do not rapidly improve.
Double Depression Tests, Quizzes, & Self-Assessment Tools
Feeling curious or interested in your depression is a perfectly natural response, so it makes sense a person would seek out ways to establish their diagnosis through online tests, quizzes, or self-assessments. In reality, a person only needs to identify their depression before seeking professional guidance.
Tests Performed by Clinicians
Mental health clinicians may perform tests and assessments to track symptom changes over time, but to diagnose the presence of double depression, experts will usually only require an interview with the client. If the person meets the diagnostic criteria for MDD and PDD, double depression is assured.
Quizzes & Self-Assessments
Trying to self-assess for double depression is a noble cause, but often misguided. The problem here is that understanding the threshold between typical and atypical levels of depression requires the education and experience of a mental health professional. In general, a person should avoid any quizzes and tests to self-assess for depression and consult a professional.
Final Thoughts On Double Depression
The coexistence of PDD and MDD, or double depression, can be extremely difficult, but you are not alone. Remember, help is out there, all you have to do is ask for it. So, if you want to find the mental health professional who is right for you, start your search on Choosing Therapy.
Additional Resources
Those interested in reading more about depression can refer to one of the below organizations for the best information on double depression and other mental health topics.
Here are a few resources for those dealing with depression:
- 10 Best Depression Podcasts
- 15 Best Depression Blogs
- American Psychological Association
- National Alliance on Mental Illness
- National Institute of Mental Health
- Online Therapist Directory: Sort therapists by specialty, cost, availability and more. Watch intro videos and see articles written by the therapists you’re considering working with. When you’ve found a good match, book an online therapy appointment with them directly.
Are you ready to connect with a therapist but feel a little overwhelmed by all your options? Speak with one of Choosing Therapy’s Client Navigators. Client Navigators are mental health professionals who will listen to what you’re looking for in a therapist and help pair you with the best possible fit. Getting started is free, easy, and confidential.
