Major Depressive Disorder: Types, Symptoms, & Treatments

Major depressive disorder (MDD) is a debilitating mental health condition that impacts about 20 million people in the U.S. each year.¹ Also referred to as clinical depression, MDD can cause people to experience unwanted symptoms ranging from mild irritability to an extremely low mood with suicidal thoughts. Mental health professionals can provide treatment, including therapy, medication management, and lifestyle changes, that can reduce and eliminate MDD symptoms.

Symptoms of Major Depressive Disorder

Major depressive disorder and major depressive episodes have nine symptoms²:

1. Feelings of sadness, hopelessness, emptiness, or a high level of irritability
2. Increased or decreased need for sleep
3. Increased or decreased appetite with or without weight changes
4. Decreased energy
5. Less interest in activities and interests
6. Feeling or appearing sped up or slowed down
7. Poor concentration and decision-making skills
8. Feeling worthless and guilty with low self-esteem
9. Thinking about death, dying, and suicide

It’s common for people to not display all symptoms, but an MDD diagnosis requires them to experience at least five, and at least one must include having a depressed mood or loss of interest or pleasure in activities. The symptoms must present nearly every day and most of the day for two weeks to count as MDD. Also, these symptoms must negatively influence performance and ability to function at home, work, school, and in the community.²

To be considered MDD, symptoms cannot be due to the effects of a substance or a medical condition. It is important to see a physician to rule out any physical problems that may be contributing to symptoms.

Major Depression Severity & Specifiers

Low motivation, sadness, and increased need for sleep are common in typical depression, but there are many types of major depressive disorder. Major depressive disorder can vary by the severity of symptoms, the recurrence of symptoms, and a list of specifiers that describe the unique properties of the individual’s condition.

Major Depression Severity

Experts distinguish major depressive disorder by three severity classifications²:

• Mild: With mild MDD, a person will have few symptoms of the condition, and the symptoms they do have are not very intense. The symptoms will not significantly affect the person’s functioning, and their loved ones may not even perceive the depression.
• Moderate: Moderate MDD represents a level of depression that may create noticeable changes to the person’s presentation and performance at home, work, or school. There will be more symptoms or more intense symptoms.
• Severe: When the MDD is severe, the person will have many intense symptoms. The symptoms will cause so much distress that the person is unable to maintain employment, social relationships, and household responsibilities.

Along with the severity, experts differentiate depression by the frequency of symptoms. A person could experience a single episode of depression or recurrent episodes if symptoms alleviate and then return later.

Major Depressive Disorder Specifiers

Major depressive disorder specifiers describe additional aspects of the condition. There are eight MDD specifiers with the most common being²:

• Psychotic features: MDD with psychotic features can produce many harmful symptoms like delusional thinking or hallucinations. Delusions can make the person believe all types of paranoid or bizarre ideas, and hallucinations can make the person think they are hearing, seeing, feeling, smelling, or tasting things that are not there.
• Peripartum onset: Peripartum onset refers to depression that first emerges during pregnancy or in the weeks soon after birth. MDD with peripartum onset is a powerful specifier because the women may experience intense anxiety or psychotic symptoms that endanger themselves or their children. This condition affects as many as 6% of new mothers.²
• Seasonal pattern: Though it may be referred to as seasonal affective disorder, MDD with seasonal pattern involves symptoms worsening and improving based on the seasons. Typically, someone will experience more intense depressive symptoms in the winter and a return to normal moods in the spring and summer.
• Anxious distress: This specifier is added to the diagnosis when a person reports anxiety symptoms only during a period of depression. The person may feel tense, restless, fearful, and weak concentration that dissipate when the depression lifts.

Other major depressive disorder specifiers include²:

• Mixed features – the presence of manic or hypomanic symptoms with depression
• Melancholic features – marked by the inability to feel pleasure
• Atypical features – seen in the mood temporarily improving due to compliments or visits from loved ones before returning to sadness
• Catatonia – when the person will not communicate, move, or respond to people or the environment

Understanding the major depressive disorder types and specifiers helps people with the condition and experts improve symptom identification and treatment options.

Depression in Different Populations

Major depressive disorder affects all people without regard to their age, gender, cultural background, or religion. Signs and symptoms of major depressive disorder are common in the U.S. as well as around the world.

Though it is impossible to predict who will have MDD, certain risk factors can increase the odds of a major depressive episode. Some risk factors for depression are³:

• Individual differences in brain structure and functioning
• Genetics and other family members who have depression
• Personality issues like chronic low self-esteem and a pessimistic world view
• Environmental factors like trauma, abuse, neglect, poverty, and chaotic environments

The National Institute of Mental Health (NIMH) found trends of depressive episodes that exist in certain groups. Those with high rates of depression include¹:

• Adult and adolescent females. Out of all the groups, adolescent females had the highest rates of depression, regardless of other factors. About 20% of female adolescents reported at least one depressive episode in 2017, according to NIMH. Across ages and cultures, females report higher levels of depression
• Teens and young adults. Rates of depression are high for people between the ages of 12 and 25. As people age, their rates of depression reduce dramatically.
• Native Americans. Compared to other ethnic groups, American Indians and Alaska Natives report the highest rates of depression. This finding is true for adults and adolescents.
• Multiracial people. Regardless of their age, people identified as multiracial also report very high rates of depression.

Groups with relatively low rates of depression include Asian American adults and African American adolescents. Differences in rates of MDD and depressive episodes may be explained by cultural expectations and ways specific groups express and accept mood symptoms. No group is immune from depression.

What Major Depressive Disorder Looks Like

Depression may present very differently from person to person and group to group. Men may express their depression in ways that contrast women just as Asian Americans may experience depressive symptoms differently than Native Americans.

In many situations, the common perception of depression may involve a person weeping in bed with the curtains drawn as she cannot gather the energy to engage in the expectations of her life. This view is frequently accurate, but there are other sides.

Conversely, a male with depression could experience high levels of anger, irritability, and aggression. He could start complaining of numerous physical health symptoms like headaches, or he could begin engaging in risky and dangerous behaviors like substance use, gambling, or casual sex as a way to self-medicate his mood.⁴

The focus on physical ailments and body symptoms will be more frequent from people in different cultures as well.² They may be more likely to engage in negative coping skills like substance use as a way to avoid or escape from their depressed feelings.

Treatment of Clinical Depression

With a professional treatment plan, usually consisting of therapy, medication management, and at-home lifestyle changes, depressive symptoms can improve. There is no set treatment appropriate for all people, though, so each person should have an approach tailored to their individual needs, abilities, and goals.

Therapy for Major Depressive Disorders

Psychotherapy, or talk therapy, typically involves a person meeting with a therapist to identify and treat symptoms linked to depression. Depending on the severity of symptoms and response to previous treatment, a person could participate in:

• Individual therapy
• Group therapy
• Family therapy

Whether it takes place in a professional’s office, online, the home, community, rehab, or inpatient hospital setting, therapy will help the person⁵:

• Gain awareness about the harmful and inaccurate ways of thinking triggered by depression
• Build healthy coping skills to improve their symptoms
• Examine and modify their relationships and interactions with other people
• Learn relaxation skills to calm their mind and body
• Track symptom changes over time
• Plan ways to stay safe and prevent suicide

People may engage in various therapies simultaneously to boost their recovery.

Common Type of Therapies

There are many types of psychotherapy, and the one a therapist uses typically depends on their education and experience. Some effective therapy styles for MDD include³:

• Cognitive-behavioral therapy (CBT): a method that examines thoughts, feelings, and behaviors to limit negative thinking and increase healthy behaviors
• Interpersonal therapy (IPT): an approach based on the notion that improving communication and relationships will improve depressive symptoms
• Problem-solving therapy (PST): a therapy focused on identifying and resolving problems to improve depression
• Acceptance and commitment therapy (ACT): a style focus on building acceptance of self and world around

Many therapy options exist to treat depression, so people should feel confident in exploring alternatives until they find a productive solution. Being honest and forthcoming with the therapist about their approach and the effects can help produce better results.

Intended Treatment Outcome & Timeline for Therapy

No matter the frequency, intensity, or style of therapy, all treatments will have the goal of decreasing the unwanted effects of depression and improving the overall well-being of the individual. Several factors will dictate the prognosis and effectiveness of treatment²:

• Severity of symptoms
• The presence of psychotic features
• Co-occurring disorders like personality and anxiety disorders
• The time between symptom onset and treatment beginning

About 40% of people with mild depression who address their symptoms quickly may see improvement in three months while 80% will see improvement within one year. Other people may never see a complete elimination of depressive symptoms with therapy, but therapy may still prove helpful as a way to prevent symptom escalation.²

Medication for Clinical Depression

Therapy is a useful tool, and the benefits can increase with the addition of antidepressant medications to the treatment plan. Many medications are available for the treatment of depression including:

• Selective serotonin reuptake inhibitors (SSRIs) – drugs like Celexa, Lexapro, Prozac, and Paxil that help to increase the amount of serotonin available for the brain to absorb.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) – a group of medications that include Cymbalta, Effexor, Pristiq, and Fetzima. These interact with both serotonin and norepinephrine in the brain.
• Atypical antidepressants – Examples include Wellbutrin, Remeron, and trazodone, which are drugs that do not operate in the body like other antidepressants.
• Tricyclic antidepressants – drugs like nortriptyline, amitriptyline, and doxepin, which are older than SSRIs and SNRIs, and they may trigger adverse side effects.⁵
• Monoamine oxidase inhibitors (MAOIs) – Parnate, Nardil, and Marplan and other older antidepressants that force a strict diet to avoid side effects.⁵

Overall, antidepressants prescribed by a psychiatrist, nurse practitioner, or other medical or mental health professional are safe, but some may produce unwanted side effects like⁵:

• Nausea, vomiting, and diarrhea
• Increased appetite and weight gain
• Sexual issues
• Increased need for sleep or insomnia
• Anxiety

Some medications may increase the risk of suicide in people age 24 and younger.⁵ Teens and young adults starting medications should receive observation from friends, parents, and their prescriber to avoid this effect. Additional precautions may also be prudent for women during pregnancy.

People interested in medication management for depression should always communicate their experience with their prescriber to limit side effects and find the best treatment options. Mental health medications are not an exact science, so patience is needed to arrive at the best choices.

Additional Depression Treatments

In situations where the depression will not respond to therapy or medications, additional treatment options are available. The person with depression and their treatment team will explore options such as³,⁴:

• Electroconvulsive therapy (ECT): When people cannot use or do not improve with antidepressants, ECT is a viable treatment. ECT involves electrical currents passing through the brain while under anesthesia. ECT advances result in limited risk other than memory loss when compared to past versions of the treatment. ECT is an older treatment, but it is a painless and effective option for people with severe depression.
• Other brain stimulation therapies: Newer options like repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS) have been available since 2008 and 2005, respectively. Research is exploring just how effective these options are for severe depression.
• Ketamine: Used legally for anesthesia and illicitly for a desired high, ketamine in low doses may improve depression symptoms.

Lifestyle Changes & Self Help for MDD

Lifestyle changes are not substitutes for professional treatment, but they may support and boost the effects of therapy and medication. Some helpful lifestyle changes are⁴:

• Spending more time with loved ones
• Sharing thoughts and feelings with trusted supports
• Increasing physical activity; even 10 minutes of walking per day can reduce symptoms
• Spending time in nature
• Focusing on smaller tasks and doing one thing at a time
• Building a stable routine that involves eating and sleeping at the same times each day
• Limiting or eliminating alcohol and other drugs
• Avoiding making major life decisions when symptoms are high

Finding and engaging in online or local support groups for people with depression can be a positive lifestyle change. By connecting with others, a person can become part of a community and learn additional strategies for confronting their depression.³

How to Get Help for Depression

Getting help for MDD does not have to be a complicated process. Once a person has made the decision to get help, a phone call to a trusted friend or mental health professional can initiate services.

Some other ways to navigate entrance into mental health treatment include:

• Sharing concerns and symptoms with the primary care physician or another doctor
• Calling for an intake with the local mental health agency
• Contacting the insurance company for information on covered providers
• Researching treatment options online
• Phoning a mental health helpline

People may be concerned about the fee for receiving professional mental health services, so learning about mental health insurance coverage will be essential as well. Federal, state, and county options may be available to help with gain and pay for medical coverage.

How to Get Help for a Loved One

The most important thing a person can do to help a loved one is to approach the situation from a stance of love, compassion, and understanding to let the loved one know you care. A loved one does not need to know all the answers. They only need to be willing to help.

To help a loved one, you can³:

• Offer support and patience
• Spend time with them engaged in healthy activities
• Listen carefully to their concerns and offer realistic suggestions
• Stay optimistic and hopeful for the future

Be sure to stress the importance of professional treatment for your loved one, and help them overcome the financial, transportation, or time obstacles in place. You can even attend the appointments with your friend or family member.

Safety is a high priority when your loved one has symptoms of depression. If your loved one appears very depressed and states an interest and plan to attempt suicide, take immediate action by calling 9-1-1. Doing so can avoid a dangerous situation and get your loved one the treatment they need.

To learn more about how you can help your loved one, you can call SAMHSA’s National Helpline: 1-800-662-HELP (4357).

How to Get Help for a Child

If the loved one is your child, you can access help by contacting their pediatrician or by scheduling an evaluation with the treatment center of your choosing. Identifying depression in children and teens can be misleading, so it is best to leave this to the professionals.

Parents can help by pointing out their concerns to the child and emphasizing the benefits of treatment. Avoid assigning guilt and blame or expressing disappointment about the situation. Instead, establish a team to fight against depression.

Depression Statistics

The distinctive characteristic of major depressive disorder is the presence of a major depressive episode. The National Institute of Mental Health reports¹:

• Nearly 9% of adult women and 20% of adolescent females experienced depressive episodes during the previous year
• About 13% of young adults (ages 18-25) and adolescents (ages 12-17) displayed depressive symptoms during the last year
• Rates of depression decrease with age. Less than 8% of people 26 to 49 and less than 5% of people 50 and over had a depressive episode
• White adults had a depression rate of 7.9% in 2017
• 8% of American Indians and Alaskan Natives adults and 16% of Native adolescents reported depression

The impact of depression and the rates of treatment illustrate the impact of the condition. According to the NIMH¹:

• About 64% of adults with depression and 71% of adolescents with depression reported severe impairment from the disorder
• Most adults in treatment received therapy and medication while only about 6% received medication only
• 60% of depressed adolescents report no treatment at all with 35% of adults receiving no treatment

Living with Depression: Coping & Managing Symptoms

Depression is a serious mental health concern, and though there are steps to coping and managing symptoms independently, a person should always seek professional treatment. With treatment established, a person can manage depression by⁷:

• Regularly monitoring their condition and mood
• Getting regular exercise to address physical and mental health needs
• Creating a regular sleep schedule to wake rested and energized
• Eating a diet built around healthy options rather than convenience
• Avoiding alcohol and other drugs. As a depressant, alcohol may only increase symptoms
• Identifying and challenging negative thinking and behavior patterns
• Focusing on activities that are best instead of what seems easy
• Finding a trustworthy treatment team comprised of professionals, friends, and family

Major Depressive Disorder vs. Bipolar, ADHD & More

Accurate diagnosis is essential to adequately treat depression, but several conditions are easily confused with the disorder. Other mental health conditions that overlap with MDD are²:

MDD vs. Other Depressive Disorders

Other depressive disorders like persistent depressive disorder, disruptive mood dysregulation disorder, and unspecified depressive disorder share many symptoms with MDD. The main differences will involve the frequency, duration, and intensity of symptoms.² A mental health professional will assess these differences to determine the correct diagnosis.

MDD vs. Bipolar Disorder

MDD and bipolar disorder share the presence of major depressive episodes, but bipolar disorders require the existence of a manic or hypomanic episode for the diagnosis. Manic and hypomanic episodes commonly come with a decreased need for sleep, high energy, increased self-esteem, and a tendency towards risky behaviors.² Tracking symptoms and taking note of manic episodes will help identify the actual condition.

MDD vs. ADHD

Attention-deficit/hyperactivity disorder (ADHD) and MDD both produce inattention, poor memory, and limited concentration. The main difference is that ADHD does not create the depressive symptoms like low mood, worthlessness, and low energy associated with MDD. People should consider all symptoms to determine the most likely diagnosis.²

MDD vs. Substance Use Disorders

Substance abuse, addiction, dependence, and withdrawal create a number of effects that mirror a depressive episode. Someone using drugs like sedatives and opioids or withdrawing from stimulants may display a depressed mood, low energy, low motivation, increased desire for sleep, and irritability. A person could have either MDD or a substance use disorder, but in many cases, they could have both.² Every person should be sure to offer all information to their provider, so they can make the proper diagnosis.

MDD vs. Sadness

At times, people may mistake moments of sadness for MDD. Many experience intense feelings of sadness without meeting all of the criteria for a diagnosis of MDD.² Sadness is an expected part of life and should not be considered depression. A mental health professional can help illustrate the differences between typical and atypical levels of sadness.

MDD and Co-Occurring Disorders

When someone has major depressive disorder, there is a strong chance they will have at least one other disorder as well. MDD frequently co-occurs with other mental health conditions like²:

• Substance use disorders
• Anxiety disorders including panic disorder
• Obsessive-compulsive disorder
• Eating disorders including anorexia and bulimia
• Borderline personality disorder

Depression Tests & Quizzes

Those interested in learning more about MDD may be drawn to depression tests, quizzes, and self-assessment tools, but they should be wary of these. Self-diagnosis is flawed and may lead to confusion and wasted resources.

Mental Health Evaluation

Only a mental health professional can accurately diagnose the presence of major depressive disorder. Since there are no tests, brain scans, or blood tests to check for depression, the evaluator will ask a series of questions to understand the symptoms, their onset, intensity, and impact to determine the appropriate diagnosis³. Only a professional can separate normal reactions to daily life from clinical depression.

Medical professionals can also ensure that there is no underlying physical health disorder triggering the depressive symptoms. Simple testing and lab work can rule out the influence of a physical condition.

Additional Resources for Depressive Disorders

For more information about depression, please refer to these organizations:

• Mental Health America – Depression Screening
  • Also available in Spanish
• American Psychiatric Association
• American Psychological Association
• National Alliance on Mental Illness 
• National Institute of Mental Health