What is Depression? From Diagnosis to Treatment

Depression is a widespread mental health issue that goes beyond mere sadness. It impacts millions globally, with symptoms ranging from persistent feelings of hopelessness to changes in sleep patterns and appetite. This article aims to provide a comprehensive overview of depression, covering its symptoms, types, causes, and available treatments.

Understanding Depression

Depression, also known as major depressive disorder, is a serious yet common mental health condition that can profoundly impact a person’s emotions, thoughts, actions, and views of the world [2]. It is characterized by persistent sadness and a loss of interest [6].

A 2023 national survey revealed that nearly 29% of adults have been diagnosed with depression at some point in their lives, and approximately 18% are currently experiencing it [2]. While depression can affect anyone, it’s more commonly diagnosed in women, who are 1.5 to 3 times more likely to experience it than men [15]. Women also face unique risk factors, such as hormonal changes related to menstruation, pregnancy, postpartum period, and menopause.

Although depression can occur at any age, it typically emerges in the late teens to mid-20s [2]. Despite effective treatments like antidepressants and therapy, many people with depression avoid seeking help due to stigma [6].

Signs and Symptoms of Depression

Depression is characterized by persistent feelings of sadness and loss of interest. Symptoms of depression include [6]:

• Sadness or emptiness
• Irritability
• Sleep disturbances
• Changes in appetite leading to weight gain or loss
• Low energy or fatigue
• Difficulty concentrating
• Feelings of guilt or worthlessness
• Recurrent thoughts of death or suicide
• Physical symptoms like chronic pain

Depression presents differently in men. They might be less likely to seek help and can show symptoms such as anger, irritability, and risk-taking behaviors rather than overt sadness [4], potentially leading to underdiagnosis.

Types of Depression and Mood Disorders

Depression can come in many forms. When someone begins to show signs of depression, such as unexplained sadness, irritability, difficulty falling asleep, social withdrawal, memory loss, and/or personality changes, they may think that they are ‘depressed.’ However, many people do not realize that there are several types of depression, and being able to identify which depression type your symptoms most closely identify with can make all the difference when it comes to identifying the root cause and the best treatments. The common feature between all types of depressive disorders is a sad, empty, or irritable mood and clinically significant associated symptoms. What tends to differ are the durations, timing, and cause.

Major Depressive Disorder (MDD)

Major Depressive Disorder is one of the six types of depression. It causes many people to experience a persistently depressive mood, causing individuals to undergo significant impairments in their everyday lives. The causes of this disorder can be biological, psychological, or a combination of both. This disorder is typically characterized by:

• Feelings of constant sadness or hopelessness
• Low self-esteem
• Being irritable or unwilling to interact with others in social situations
• Finding it difficult to make decisions or have the motivation to complete daily tasks
• Trouble concentrating
• Insomnia and/or fatigue
• Having no interest in hobbies or activities that you used to enjoy

Persistent Depressive Disorder (Dysthymia)

Persistent depressive disorder, also called dysthymia, is characterized by chronic depression symptoms that aren’t as severe but last much longer, typically for at least two years. People with this condition may have episodes of major depression along with periods of less severe symptoms [11].

Bipolar Disorder

People with bipolar disorder experience depressive episodes, during which they feel extremely sad, indifferent, or hopeless, combined with very low activity levels. In addition to depressive episodes, they also experience manic or hypomanic episodes, characterized by unusually elevated moods, increased energy, and activity levels. During manic episodes, individuals might feel excessively happy, irritable, or “up.” [11].

Seasonal Affective Disorder (SAD)

Seasonal Affective Disorder is a mood disorder characterized by depression that occurs at the same time each year. Many people who suffer from this disorder tend to live in places where it gets significantly darker and colder in the winter months, while others may experience SAD during the summer months, particularly as they juggle additional work, family, and social obligations. Symptoms of SAD include:

• Symptoms recurring seasonally
• Feeling depressed, mostly all day, every day
• Low energy levels creating a sluggish or agitated mood
• Difficulty focusing and/or concentrating
• Loss of interest in activities you used to enjoy participating in
• Appetite changes
• Weight gain
• Mood swings

Peripartum Depression (PPD)

Peripartum depression falls under MDD but with peripartum onset. PPD is a type of depression that usually occurs between the time a woman is pregnant and the first month following childbirth, but it can often lead to the development of MDD later in life. It is often characterized by:

• Insomnia and related lack of energy
• High levels of irritability
• Lack of concentration
• Feelings of guilt, anxiety, and/or panic attacks
• Mood swings
• Difficulty bonding with the new baby
• Loss of appetite

Premenstrual Dysphoric Disorder (PMDD)

Premenstrual Dysphoric Disorder is a disorder similar to PMS, but it is more serious because it tends to be characterized by more intense symptoms (symptoms tend to lessen in intensity 3-4 days after the woman’s period starts), such as:

• Severe irritability (more intense than what is usually caused by premenstrual syndrome)
• Depression and/or anxiety experienced in the weeks prior to a woman’s period
• Mood swings, including anger and sadness
• Insomnia or sleeping in excess
• Appetite changes and bloating
• Less interest in usual hobbies or activities
• Cravings for specific foods

Disruptive Mood Dysregulation Disorder (DMDD)

Disruptive mood dysregulation disorder (DMDD) is diagnosed in children and adolescents; this disorder involves severe irritability, anger, and frequent, intense temper outbursts [11]. While moodiness is common in children, those with DMDD experience severe symptoms that significantly affect their daily lives, including problems at home, school, and in interactions with peers [12].

Persistent Depressive Disorder (Chronic MDD & Dysthymia)

Persistent Depressive Disorder is a usually mild, yet long-term form of depression associated with Dysthymia, which is defined as having a depressed mood for at least two years in addition to experiencing at least two other symptoms of depression. It is usually characterized by:

• A depressed mood most of the time for an extended amount of time
• Feelings of hopelessness
• Eating unhealthily (sometimes in excess amounts)
• Inability to sleep or sleeping for excessive amounts of time
• Low energy
• Poor concentration
• Low self-esteem

Cyclothymic Disorder

Cyclothymic disorder is an affective disorder characterized by emotional reactivity and affective dysregulation [5]. Often challenging to diagnose due to non-specific symptoms, cyclothymia shares diagnostic features with various psychiatric disorders [5]. It is part of the bipolar mood disorders category in the DSM-5 and involves hypomanic and depressive symptoms that don’t meet the full criteria for bipolar or major depressive disorder [5].

Recognizing the specific type of depression or mood disorder is the first step toward effective treatment. Each type requires a tailored approach to manage symptoms and improve quality of life.

Substance/Medication-Induced Depressive Disorder

Substance/medication-induced Depressive Disorder is one of the more chronic types of depressive disorders because the substances that cause this disorder can be serious threats to the health of the individual experiencing the disorder. This type of depressive disorder is usually characterized by the following symptoms (during or soon after taking various substances and/or medications):

• A depressed and sad mood most of the time each day
• High levels of anxiety
• Psychotic or manic symptoms occuring mainly from the abuse of substances and/or medications
• Irritability
• Trouble sleeping
• Weight gain or loss
• Lack of interest in previous hobbies

Causes of Depression

Depression can be caused by a mix of factors, such as genetic predispositions, environmental stressors, traumatic life events, biochemical imbalances, and psychological factors [6]. These factors interact in complex ways, affecting how people experience and respond to depression [6].

Genetic Factors

Genetic factors play a role in depression, as the condition tends to run in families, pointing to a genetic link. If someone has close relatives with depression, they are more likely to develop depression themselves [2]. For example, if one identical twin has depression, the other twin has a 70% likelihood of experiencing it at some point [2]. Genetic factors affect how individuals respond to stress and manage their emotions, making them more susceptible to depression [2].

Biochemical Causes of Depression

Differences in brain chemicals, such as serotonin, dopamine, and norepinephrine, can contribute to symptoms of depression [2]. These neurotransmitters play crucial roles in regulating mood, and imbalances may lead to feelings of sadness, hopelessness, and other depressive symptoms [2].

Environmental and Life Stressors

Continuous exposure to environmental stressors such as violence, neglect, abuse, or poverty can overwhelm coping mechanisms and disrupt brain function, leading to persistent feelings of sadness and hopelessness. Traumatic life events, such as the loss of a loved one, divorce, job loss, or chronic illness, can also trigger depression and exacerbate symptoms [6, 14].

Medical Conditions

Certain medical conditions, including chronic illnesses like cancer or heart disease and neurological disorders such as Alzheimer’s disease or stroke, are associated with higher rates of depression. These conditions can both contribute to and exacerbate depressive symptoms [6,14].

Adverse Childhood Experiences

Childhood trauma, such as abuse or neglect, significantly increases the risk of depression later in life [14]. How individuals interpret and cope with such experiences plays a crucial role in determining their resilience to depression [14].

Inflammatory Response

Increasing evidence suggests that inflammation in the body, triggered by stress and negative emotions, plays a role in the onset and worsening of depression. Chronic inflammation can disrupt brain function and exacerbate depressive symptoms.

Psychological Factors

Perfectionism, negative thinking patterns, and learned helplessness can predispose individuals to depression [14]. Constantly focusing on perceived failures and shortcomings can lead to distorted self-view and persistent feelings of inadequacy [14].

Hidden Triggers

Depression can sometimes appear without an obvious cause, stemming from deep-seated beliefs and expectations about life and personal achievements [14]. Even achieving long-desired goals may not bring the expected emotional fulfillment, leading to feelings of confusion and shame [14].

Related: What Causes Mental Illness?

Comorbid Conditions

Individuals with substance use disorder (SUD) commonly experience co-occurring mental health disorders such as anxiety, depression, ADHD, bipolar disorder, personality disorders, or schizophrenia [13].

Anxiety Disorders

Anxiety disorders frequently co-occur with depressive disorders. These disorders involve excessive worry, fear, or apprehension, often leading to avoidance behaviors that impact daily life. Anxiety disorders are frequently found alongside major depressive disorder (MDD) and can intensify depressive symptoms. Various forms, such as panic disorder, agoraphobia, social phobia, obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD), are commonly associated with depressive symptoms [13, 16].

Substance Use Disorders (SUD)

Depression frequently co-occurs with substance use disorders, where individuals may use substances to alleviate depressive symptoms temporarily [13]. However, relying on substances can exacerbate depressive symptoms over time and lead to dependence [13]. Integrated treatment approaches are crucial for addressing both depression and SUDs simultaneously, aiming to improve outcomes and overall well-being [13].

Other Comorbid Conditions:

• Attention-Deficit Hyperactivity Disorder (ADHD): ADHD, characterized by difficulty sustaining attention, hyperactivity, and impulsivity, can exacerbate feelings of distress and low mood when occurring alongside depression [13].
• Bipolar Disorder: Bipolar disorder involves alternating periods of depressive episodes and manic or hypomanic episodes, significantly affecting mood and energy levels [13].
• Personality Disorders: Certain personality disorders, such as borderline personality disorder, may co-occur with depression, characterized by persistent patterns of behavior, cognition, and inner experience that deviate from cultural expectations  [13].
• Schizophrenia: Schizophrenia, a severe mental disorder, may include depression as a secondary feature alongside disturbances in thought, perception, and behavior [13].
• Dysthymia: Dysthymia, another mood disorder, often coexists with major depressive disorder (MDD), presenting with chronic, milder symptoms that persist over years [16].
• Psychotic Disorders: Less commonly, psychotic disorders like schizophrenia can overlap with MDD, characterized by hallucinations, delusions, or severe disorganized thinking [16].
• Antisocial Personality Disorder: This disorder, involving disregard for others’ rights, can co-occur with MDD and presents unique challenges in treatment due to its interpersonal aspects [16].

When to Seek Help

Feeling unsure about seeking help for depression or other mental health issues is normal. It’s important to pay attention to significant changes in your thoughts, feelings, and behaviors, like noticeable changes in behavior, disruptions in eating or sleeping habits, or difficulty handling everyday tasks [9].

If you’re feeling out of sync with your usual routine, dealing with a lot of anxiety, or experiencing prolonged sadness or thoughts of suicide, it might be time to seek professional help  [9]. Many people tend to brush off these symptoms or hold back because of the associated stigma, but ignoring them can make things worse [9].

If you notice these signs in yourself or someone you care about, reaching out to a primary care doctor or a mental health professional is the next best step [9]. These professionals can assess your situation thoroughly and recommend suitable treatments, such as medications, counseling, or a mix of both, personalized to your needs [9]. By seeking assistance early, you can enhance your quality of life and overall well-being. Remember, seeking help is a proactive step towards understanding and managing mental health difficulties effectively [9].

How is Depression Diagnosed?

Diagnosing depression involves a thorough evaluation by a healthcare professional, such as a psychiatrist, psychologist, or primary care physician. They will inquire about your symptoms, medical history, and any factors that could contribute to your depression. A physical exam may also be conducted to rule out underlying medical conditions.

Depression is diagnosed according to specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. To receive a diagnosis of Major Depressive Disorder (MDD), several criteria must be met  [1]:

• Experience at least five symptoms of depression.
• These symptoms occur nearly every day, for most of the day, over at least two weeks.
• Must include either a persistent depressed mood or a loss of interest or pleasure in almost all activities.
• Symptoms cause significant distress or impair social, occupational, or other important areas of functioning.
• Symptoms are not due to another medical condition or substance use.

Sometimes, additional psychological tests or assessments may help clarify the depression diagnosis and understand the severity of symptoms. The healthcare provider may also consider other conditions that could mimic depression or coexist with it, such as anxiety disorders, bipolar disorder, or medical conditions like thyroid disorders.

How is Depression Treated?

While depression can be a debilitating condition, it is treatable. Depression treatment combining psychotherapy and antidepressant medication is often effective in managing symptoms and promoting healing.

Psychotherapy

Several forms of talk therapy are recommended for treating depression in adults [3]:

Cognitive-behavioral therapy (CBT)

CBT integrates cognitive and behavioral techniques to address current problems and symptoms of depression. It focuses on understanding the connection between thoughts, behaviors, and emotions. By identifying negative patterns and replacing them with more constructive ones, CBT helps individuals develop coping strategies and problem-solving skills. This structured approach aims to enhance mood regulation and improve overall functioning.

Behavioral Therapy

Behavioral therapy targets current problems and symptoms by focusing on changing patterns of behavior that contribute to difficulties in functioning. It emphasizes the relationship between behavior and mood, aiming to modify behaviors that exacerbate depressive symptoms. Techniques such as behavioral activation help individuals engage in positive activities and routines, which can improve mood and reduce avoidance behaviors that maintain depression.

Interpersonal Therapy (IPT)

Interpersonal psychotherapy concentrates on improving relationships and addressing life circumstances closely linked to the current depressive episode. It explores issues such as grief, role transitions, interpersonal disputes, and social isolation. IPT helps individuals develop healthier communication and relational patterns, thereby alleviating depressive symptoms associated with interpersonal difficulties.

Mindfulness-Based Cognitive Therapy (MBCT)

MBCT combines cognitive therapy with mindfulness meditation practices. It aims to cultivate present-moment awareness and acceptance of one’s experiences. By integrating mindfulness techniques, individuals learn to observe their thoughts and emotions without judgment, reducing reactivity to negative thinking patterns that contribute to depression. MBCT promotes resilience and emotional regulation, enhancing overall well-being.

Psychodynamic Therapy

Psychodynamic therapy focuses on exploring unconscious thoughts and early life experiences that influence current challenges. It aims to increase self-awareness and understanding of how past experiences shape present behaviors and relationships. Through the therapeutic relationship, individuals gain insight into unresolved conflicts and develop adaptive ways of coping with emotions, ultimately promoting psychological growth and symptom relief.

Related: Depression Therapy: A Comprehensive Approach to Healing

Medication

Effective treatment for depression often includes psychiatric medication options that aim to alleviate symptoms and improve overall well-being [7, 17].

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are commonly prescribed to treat depression. They work by increasing the levels of serotonin in the brain, which helps improve mood. Some widely known SSRIs include citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac). Common side effects may include nausea, nervousness, and sleep problems. In rare cases, SSRIs can cause serious side effects like seizures or abnormal bleeding. It’s important to discuss all potential risks with your healthcare provider.

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

SNRIs help treat depression by boosting serotonin and norepinephrine levels in the brain. This can improve mood and reduce feelings of anxiety. Medications in this category include duloxetine (Cymbalta) and venlafaxine (Effexor). Common side effects are nausea, dry mouth, and dizziness. Serious side effects might include increased blood pressure or seizures, so it’s essential to monitor your health and consult your doctor regularly.

Tricyclic and Tetracyclic Antidepressants

These older antidepressants are less commonly prescribed due to their side effects but can be effective for some people. Examples include amitriptyline (Elavil) and nortriptyline (Pamelor). They can cause dry mouth, blurred vision, and drowsiness. More severe side effects can include heart rhythm problems or seizures. Always talk to your healthcare provider about the risks and benefits of these medications.

Atypical Antidepressants

Atypical antidepressants don’t fit neatly into other categories. They include medications like bupropion (Wellbutrin) and mirtazapine (Remeron). Common side effects vary but can include dry mouth, dizziness, and weight gain. Serious risks might involve seizures or changes in blood pressure. Discuss any concerns with your healthcare provider to find the proper medication.

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs are typically used when other antidepressants haven’t worked. They include drugs like phenelzine (Nardil) and tranylcypromine (Parnate). They can interact with certain foods and medications, so dietary restrictions and close medical supervision are necessary. Common side effects are nausea and dizziness, while serious risks include severe headaches and changes in blood pressure.

Neuroactive Steroid Gamma-Aminobutyric Acid (GABA)-A Receptor Positive Modulator

Brexanolone (Zulresso) is one of the newest antidepressants specifically approved for postpartum depression. It is administered via IV infusion in a certified healthcare facility for over 60 hours. Side effects can include sedation and loss of consciousness. Due to its risks, it’s only available under a strict monitoring program [17].

Depression medications can be very effective, but they all come with potential side effects. Always discuss your options thoroughly with your healthcare provider to find the safest and most effective treatment for you.

Transcranial Magnetic Stimulation (TMS)

First-line treatments for depression typically include talk therapy and psychiatry for medication management. However, only approximately 30% of people with depression fully respond to those conventional treatments. Transcranial magnetic stimulation (TMS) is a highly effective treatment alternative for depression that can be used alone or in conjunction with therapy and medication.

TMS is a non-invasive medical procedure approved by the FDA to treat depression when other treatments haven’t been successful [10]. It’s also FDA-approved for treating obsessive-compulsive disorder (OCD), migraines, and smoking cessation [10].

During a TMS session, an electromagnetic coil is placed on the scalp [10]. This coil emits magnetic pulses that target nerve cells in the brain areas involved in mood regulation and depression [10]. The pulses used in brain stimulation therapy are believed to activate parts of the brain that are less active in people with depression, helping to improve symptoms [10]. The specific method of delivering these pulses, known as repetitive TMS (rTMS), involves repeated magnetic pulses over a session [10].

TMS is generally safe and well-tolerated, with mild side effects, including scalp discomfort, headaches, and facial muscle twitching [10]. Serious side effects like seizures are rare. Before starting TMS, patients undergo a physical and mental health evaluation to ensure the treatment is appropriate for them [10].

Related: TMS for Depression

Depression Treatment in California

Depression is a prevalent mental health condition that can profoundly impact individuals’ emotions, thoughts, and daily functioning. Recognizing the symptoms, understanding the different types of depression and mood disorders, and seeking appropriate treatment are essential steps in effectively managing this complex condition.

Dealing with depression can be incredibly challenging, but it’s important to remember that help and support are available. The psychiatrists at Neuro Wellness Spa are experts in depression treatment and will work with you to go over the available options for you and whether you need psychiatric medication management, talk therapy, TMS therapy, or MeRT.

At Neuro Wellness Spa, we prioritize personalized care, understanding that each individual’s journey is unique. Whether you prefer in-person or online sessions, our team of compassionate professionals is here to support you. Reach out today to learn more about our in-person and online psychiatry for medication management, talk therapy covered by insurance, and alternative treatments like TMS therapy. Call us today to explore how we can assist you on your path to wellness.

References:

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition. Washington DC. Retrieved from https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596
2. American Psychiatric Association. (n.d.). What is Depression? Retrieved from https://www.psychiatry.org/patients-families/depression/what-is-depression
3. American Psychological Association. (n.d.). Depression Treatments for Adults. Retrieved from https://www.apa.org/depression-guideline/adults
4. Anguzu, R., Nagavally, S., Dawson, A. Z., Walker, R. J., & Egede, L. E. (2021). Age and Gender Differences in Trends and Impact of Depression on Quality of Life in the United States, 2008 to 2016. Women’s health issues: official publication of the Jacobs Institute of Women’s Health, 31(4), 353–365. https://doi.org/10.1016/j.whi.2021.02.005
5. Bielecki JE, Gupta V. (2023). Cyclothymic Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK557877/
6. Chand SP, Arif H. (2023). Depression. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430847/
7. Cleveland Clinic. (n.d.). Antidepressants. Retrieved from https://my.clevelandclinic.org/health/treatments/9301-antidepressants-depression-medication
8. National Institute of Mental Health. (n.d.). Major Depression. Retrieved from https://www.nimh.nih.gov/health/statistics/major-depression
9. Mayo Clinic. (2024). Managing your mental health: when is it time to get help? Retrieved from https://mcpress.mayoclinic.org/mental-health/managing-your-mental-health-when-is-it-time-to-get-help/
10. Mayo Clinic. (n.d.). Transcranial magnetic stimulation. Retrieved from https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625
11. National Institute of Mental Health. (n.d.). Depression. Retrieved from https://www.nimh.nih.gov/health/topics/depression
12. National Institute of Mental Health. (n.d.). Disruptive Mood Dysregulation Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/disruptive-mood-dysregulation-disorder-dmdd
13. National Institute of Mental Health. (n.d.). Substance Use and Co-Occurring Mental Disorders. Retrieved from https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health
14. Psychology Today. (n.d.). Causes of Depression. Retrieved from https://www.psychologytoday.com/us/basics/depression/causes-depression
15. Salk, R. H., Hyde, J. S., & Abramson, L. Y. (2017). Gender differences in depression in representative national samples: Meta-analyses of diagnoses and symptoms. Psychological Bulletin, 143(8), 783–822. https://doi.org/10.1037/bul0000102
16. Thaipisuttikul, P., Ittasakul, P., Waleeprakhon, P., Wisajun, P., & Jullagate, S. (2014). Psychiatric comorbidities in patients with major depressive disorder. Neuropsychiatric disease and treatment, 10, 2097–2103. https://doi.org/10.2147/NDT.S72026
17. U.S. Food & Drug Administration. (n.d.). Depression Medicines. Retrieved from https://www.fda.gov/consumers/womens-health-topics/depression-medicines