Depression is more than just feeling sad or having a bad day: it’s a serious and complex mental health disorder that can profoundly impact every aspect of a person’s life. Unlike a fleeting mood, “clinical depression” – which most commonly refers to major depressive disorder (MDD), though depression can be part of other mental health conditions as well – is characterized by persistent feelings of sadness and a loss of interest or pleasure in daily activities. In this post, we’ll review the symptoms of depression as well as common treatments for the symptoms.

Symptoms of depression

Depression manifests in a wide range of emotional and physical symptoms, which can vary in severity from person to person. To be formally diagnosed with a “major depressive episode,” a person must experience several symptoms for at least two weeks, most of the day, nearly every day. The diagnostic criteria are specific, but the lived experience is often an overwhelming mix of the following:

• Persistent sadness and hopelessness: a deep, pervasive feeling of sadness, emptiness, or a “down” mood. This is often accompanied by a sense of hopelessness and pessimism about the future. Irritability and anxiety are other common mood symptoms that can occur with depression.

• Loss of interest or pleasure (clinically referred to as anhedonia): a significant reduction in interest or pleasure in activities you once enjoyed, whether hobbies, social gatherings, or even intimacy. This is a core symptom of depression and required for the formal diagnosis of a major depressive episode.

• Changes in energy levels: most commonly, people with depression feel exhausted and drained, even after getting a full night’s sleep. Some people feel that there is no amount of sleep that can cause them to feel well-rested, and simple tasks can feel like monumental efforts. In some cases, people may experience the opposite: restlessness, physical agitation, and severe anxiety.

• Changes in sleep patterns: this can present as either insomnia (difficulty falling or staying asleep) or hypersomnia (sleeping much more than usual)

• Changes in appetite or weight: some people with depression experience a decreased in appetite, resulting in reduced food intake and weight loss. Others can experience an increase in appetite, often finding food to be a comfort. Many people also notice changes in what they want to eat, preferring sweets or “less healthy” foods.

• Feelings of worthlessness or guilt: experiencing excessive or inappropriate feelings of guilt or worthlessness, often stemming from distorted self-perception. People with depression may feel like a failure, like nothing they do is “good enough,” or that everything they do is “wrong.”

• Difficulty concentrating: trouble focusing, remembering details, and making decisions, which can impact work, school, and daily life. In some cases – most often in older people – the cognitive difficulties can be so severe as to resemble dementia, a condition called pseudodementia.

• Thoughts of self-harm or suicide: “suicidal thoughts” is a broad term that includes many different types of thoughts and experiences. Some people feel like others would be better off without them, some have a wish to disappear or escape without wanting to end their life, and some have thoughts of wanting to end their life. If you are having these thoughts, seek help immediately. You can speak with someone immediately by calling 988 (the national suicide prevention hotline) or going to your nearest emergency department.

In most cases, these symptoms develop and build slowly, often over the course of weeks or months. For some people, it can be difficult to recognize the changes in how they are feeling. These symptoms can interfere with relationships, work performance, and overall well-being. It’s important to understand that these aren’t character flaws or signs of weakness; instead, they are symptoms of a medical condition that can be treated.

Who experiences depression?

Despite being common, depression often is not discussed due to stigma surrounding mental health conditions. The National Institute of Mental Health estimates that just under 10% of the adult population in the United States has experienced at least one depressive episode. Approximately half of people that experience a major depressive episode go on to experience at least one more episode in their lives. The true frequency of depression is likely higher than these figures suggest as many people do not seek treatment for their symptoms.

Research has shown that depressive symptoms are more common among certain groups:

• Depression is significantly more prevalent in women than in men. Women experience major depressive episodes at approximately twice the rate of men.

• Depression is more common in adolescents and young adults compared to other age groups. Studies have found that approximately a quarter of older adolescents (ages 16-17) have experienced a major depressive episode; these rates fall with increasing age, dropping to approximately 5% in adults older than 50.

• Depression affects all ethnic groups, but studies have shown that there are differences among individual groups. Depression is most common among Indigenous Americans, approximately equally common among White, Black, and Hispanic Americans, and least common among Asian Americans.

Many factors contribute to the development of depression, and the “cause” of depression is complicated and ultimately not known. There is clear data to suggest that depression is, to at least some degree, influenced by genetics. People that have a close relative that has experienced depression are more likely to experience depression themselves compared to the general population. However, this relationship is complicated, and genetics do not appear to be the primary determinant of whether someone will develop depression in life. Other factors appear to play a larger role.

Treatments for depression

Depression is treatable, and many treatments have been developed to treat depressive symptoms. In most cases, people utilize a variety of treatment approaches, including medications, lifestyle changes, psychotherapy, and, in some cases, neuromodulatory treatments. For mild to moderate symptoms, research has shown that either medication or psychotherapy can be effective, but doing both at the same time results in the best outcomes. For severe symptoms, both psychotherapy and medication are recommended; in some cases, neuromodulatory treatments like transcranial magnetic stimulation (TMS), ketamine-based treatments, and electroconvulsive therapy (ECT) may be appropriate. While studies have shown that all of these treatments can be effective, each person responds differently to each treatment. Working with a mental health professional to explore treatment options and adjust your treatment over time will typically result in the best results.

Psychotherapy

Psychotherapy – also informally called talk therapy, therapy, or counseling – is a cornerstone of depression treatment. It provides a safe, confidential space to work through emotions and develop coping strategies. Common forms of psychotherapy include:

• Psychoanalytic/psychodynamic psychotherapy: this is the oldest and “original” form of psychotherapy, developed in the early 20th century and continuously refined through the present day. This form of psychotherapy focuses on exploring the contributors of emotional suffering; according to this theory, these contributors often occur early in life. An important aspect of this form of psychotherapy is acknowledging the presence of an unconscious, meaning that much of mental and emotional life occurs out of awareness. This form of therapy tends to focus on unearthing these unconscious thoughts and feelings, resulting in greater self-understanding and an increased ability to live an emotionally authentic life.

• Cognitive behavioral therapy (CBT): this form of psychotherapy, developed in the 1950s, was developed by a psychoanalyst to incorporate psychological research on learning into psychotherapeutic treatment. This form of therapy focuses on understanding how thoughts, feelings, “core beliefs,” and behaviors relate to one another, often resulting in the development of patterns of thinking and feeling that result in symptoms. CBT tends to be a problem- and symptom-focused therapy that includes an active relationship between the patient and therapist.

• Dialectical behavioral therapy (DBT): DBT is a modified form of CBT originally developed in the 1970s for the treatment of borderline personality disorder. However, DBT has found to be helpful for people without borderline personality disorder and is commonly used in the treatment of other symptoms and conditions. Like CBT, DBT tends to be problem- and symptom-focused, addressing specific symptoms in an active, pragmatic way. Core goals of DBT are to improve emotional regulation, increase the ability to tolerate distress, and improve interpersonal relationships.

Many forms of psychotherapy have been developed and are used clinically. While the specific techniques used in each type of therapy varies, all share the same goal of talking about your thoughts, emotions, and experiences to improve self-understanding, develop resilience, and lessen emotional suffering. Psychotherapy is provided by many different mental health professionals, including master’s level therapists, psychologists, and, more rarely, psychiatrists.

Medication

Medications called antidepressants are commonly used to treat depressive symptoms. These medications are also used for other mental health conditions, including anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, and other conditions. These medications work by changing how chemicals, called neurotransmitters, function in the brain.

There are many different antidepressants that are used clinically. While there are nuanced differences among these medications, all of them have been shown to be effective in treating depression, and there is no “best” antidepressant. With some exceptions, all antidepressants have the potential to cause they same set of side effects. Individual people respond differently to different medications, and it is nearly impossible to predict what specific medication may be helpful for a specific person. This can be a frustrating aspect of medication treatment as you may feel like a guinea pig, trying several different medications before finding one that will work effectively for you. Our post on antidepressants has more extensive information about these medications.

Antidepressants in clinical use today include:

• Selective serotonin reuptake tnhibitors (SSRIs): fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), citlaopram (Celexa), paroxetine (Paxil), and fluvoxamine (Luvox)

• Serotonin-norepinephrine reuptake inhibitors (SNRIs): venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), and levomilnacipran (Fetzima)

• Serotonin modulators: vilazodone (Viibryd), vortioxetine (Trintellix), trazodone (Desyrel), and nefazodone (Serzone)

• “Atypical” antidepressants: mirtazapine (Remeron) and bupropion (Wellbutrin)

• Tricyclic antidepressants (TCAs): amitriptyline (Elavil), nortriptyline (Pamelor), clomipramine (Anafranil), and imipramine (Tofranil), among others

• Monoamine oxidase inhibitors (MAOIs): tranylcypromine (Parnate), isocarboxazid (Marplan), selegilene (Emsam), and phenelzine (Nardil)

In some cases, other medications may be used along with an antidepressant, typically if an antidepressant is helpful but does not fully treat symptoms that are present. Commonly used medications for this purpose include aripiprazole (Abilify), brexpiprazole (Rexulti), and lithium, among others.

Lifestyle modifications

Beyond professional therapy and medication, lifestyle changes play a crucial role in managing depression.

• Regular exercise: physical activity has been shown to be effective for mild to moderate depression. Engaging in at least 90 minutes of light exercise – which includes walking – each week has been shown to be as effective as an antidepressant in some studies.

• Diet: while the research surrounding the impact of diet on emotional wellbeing is complicated, most guidelines recommend incorporating a balanced, healthy diet that includes fruit, vegetables, high quality protein, and minimally processed foods. There is some evidence to suggest that inflammation may contribute to depressive symptoms, and some foods – most commonly highly processed foods like fast food – may cause chronic inflammation.

• Reaching out to your support network: in many cases, depression can be a significant barrier to doing usual activities and socializing with others. Paradoxically, however, a more intentional effort to spend time with others can reduce the feelings of loneliness and isolation that often accompany depression.

Help is available!

Because many different treatments are available to treat depression, meeting with a clinician to discuss your your symptoms and potential options for treatment can be the first step to recovery. If you’re struggling with these symptoms and would like receive help, please contact us to schedule an initial consultation.