What symptoms must be present for a diagnosis of major depressive disorder?

What is Major Depressive Disorder (MDD)?

While everyone experiences sadness or depression from time to time, major depressive disorder – also known as clinical depression – is defined as a depressed mood or loss of interest or pleasure in almost all activities that persists for at least two weeks and represents a change from previous functioning. Major depressive disorder causes significant distress or severely impacts a person’s social or work life and other daily routines. It can be diagnosed as mild, moderate or severe, and psychotic symptoms – such as delusions or hallucinations – may be present. 

Signs and Symptoms of Major Depressive Disorder

For a diagnosis of major depressive disorder, five or more of the following characteristics must be present during the same two-week period, represent a change from previous functioning, and include at least one of the major symptoms: depressed mood or loss of interest or pleasure.

Symptoms, which must be present nearly every day, include:

• Depressed mood most of the day, nearly every day, as indicated by self-reporting or through observations made by others; in children and adolescents, this can present as irritability
• Markedly diminished interest or pleasure in all, or almost all, activities for most of the day
• Significant weight loss (without dieting) or weight gain or a decrease or increase in appetite
• Insomnia (inability to sleep) or hypersomnia (excessive sleepiness)
• Inner restlessness or tension associated with increased motor movement (psychomotor agitation) or a slowing-down of thought and a reduction of physical movement (psychomotor retardation), observable by others
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
• Diminished ability to think, concentrate or make decisions
• Recurrent thoughts of death (not just fear of dying), suicidal thoughts without a specific plan, or a suicide attempt or a specific plan for committing suicide

The symptoms mentioned above must follow the following diagnostic criteria:

• Cause significant distress/impairment in social, occupational or other functional areas
• Not be attributable to physiological effects of a substance or other medical condition
• Not be better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders
• Not be the result of bereavement or another significant tragedy
• Not occur in addition to a manic episode (a mood state characterized by period of at least one week where an elevated, expansive, or unusually irritable mood exists) or hypomanic episode (a distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity or energy, lasting at least four consecutive days and present most of the day, nearly every day)

Major depressive disorder that continues for more than two years is called persistent depressive disorder or dysthymia.

Major Depressive Disorder Diagnosis

Diagnosing major depressive disorder requires thorough physical and psychological evaluation. Your behavioral health physician will use the criteria for depression listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, to determine if your symptoms indicate major depressive disorder.

Diagnostic tests include:

Blood tests: Your physician may order a complete blood count or test your thyroid hormone levels to be sure the thyroid is functioning properly.

Physical examination: Your physician will perform a physical exam and ask questions about your health to determine if your symptoms could be linked to an underlying physical health problem.

Psychiatric evaluation: Your behavioral health physician will ask about your symptoms, thoughts, feelings and behavior patterns. You may be asked to fill out a questionnaire to help answer these questions.

A Major Depressive Disorder diagnosis can present in a variety of ways and include the following specifiers: 

• With anxious distress
• With mixed features
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern

A clinician will also work to differentiate your symptoms from other forms of depression, such as persistent depressive disorder, bipolar I and II, grief, and post traumatic stress disorder. 

Causes of Major Depressive Disorder

The cause of major depressive disorder is unknown, but symptoms can stem from a variety of factors.

Risk Factors

Risk factors that could contribute to major depressive disorder include:

Biological differences: Physical changes in the brain can be seen in some people with major depressive disorder. What leads to these changes, and their significance, is still unclear. 

Brain chemistry: Neurotransmitters, naturally occurring brain chemicals, likely play a role in depression. Recent research indicates that changes in the function and effects of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.

Family history: Major depressive disorder is more common in people whose blood relatives also have the condition. Research into genetic causes of depression is ongoing. First-degree family members of individuals with major depressive disorder have a risk for major depressive disorder two- to-four- times higher than that of the general population.

Gender: More women than men are diagnosed with major depressive disorder, but this may be due to the fact that women are more likely to seek treatment.

Hormones: Changes in a person’s hormone balance may trigger or cause depression. These hormonal shifts may occur during pregnancy, after childbirth, during menopause or as a result of thyroid disease or other health conditions.

History of other mental health disorders: People with a history of anxiety disorders, eating disorders or post-traumatic stress disorder may be at an increased risk of developing major depressive disorder.

Serious or chronic illness: In major depressive disorder, serious or chronic illnesses aren’t leading to symptoms directly, but rather may be triggering depression via associated psychological and emotional effects.

Traumatic or highly stressful events: While experiencing short-term feelings of depression or loss of interest in daily activities is typical following the death or loss of a loved one, abuse, a difficult relationship or major financial problems, these events can also trigger brain changes that may lead to major depressive disorder. Adverse childhood experiences, particularly when there are multiple experiences of diverse types, are potent risk factors for major depressive disorder.

Prevention

While most risk factors for major depressive disorder are unknown, or can’t be controlled, there are ways you can help improve your mental health:

Don’t abuse alcohol or recreational drugs: These substances have a mood-altering effect that could trigger depressive symptoms.

Seek help for known behavioral issues: If you recognize – or have been told by others – that you have low self-esteem, dependent tendencies, or self-critical or pessimistic tendencies, behavioral health counseling or therapy may help.

Seek support for stress: Lean on family and friends, if possible, during stressful situations. Talking to a behavioral health professional can also help you develop effective coping strategies.

Talk to your physician about side effects: If you’re experiencing symptoms of depression after starting a new medication, or taking a new dosage, talk to your physician about alternative options.

Prognosis

Most cases of major depressive disorder can be treated – and the earlier treatment begins, the more effective it tends to be.

Treatment

Most people with major depressive disorder benefit most from a combination of medication and psychotherapy delivered by a psychiatrist, psychologist or other behavioral health professional.

Preventing Suicide

If you are thinking about suicide, please go the nearest medical emergency room, call 911, or call the National Suicide Prevention Lifeline at 1.800.SUICIDE (1.800.273.8255). The National Suicide Prevention Lifeline provides free and confidential support to persons in crisis 24 hours a day, seven days a week, every day of the year from anywhere in the United States. There is also a Web site: https://suicidepreventionlifeline.org.

Medications for Major Depressive Disorder

You may need to try a few different antidepressant medications, or medication combinations, before you find the one that’s right for you. Some medications take a few weeks before their full effect is obvious. Some cause side effects for certain patients. If you experience any side effects, it’s important to talk to your physician immediately but not to abruptly stop taking the medication, which could cause a worsening of symptoms.

Discuss all potential risks of your prescribed medication. Many antidepressants shouldn’t be taken by pregnant or nursing mothers, as they could harm the baby. Others shouldn’t be taken by children, teens or younger adults because they can increase suicidal thoughts.

Most antidepressants are generally safe, but their prescription and use should always be under the guidance of a medical professional.

Common antidepressants include:

• Selective serotonin reuptake inhibitors (SSRIs): These first-line antidepressants are considered safer than other types and tend to cause fewer disruptive side effects. They increase levels of serotonin in the brain.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs): These block the reabsorption of the neurotransmitters serotonin and norepinephrine in the brain. 
• Tricyclic antidepressants: These older drugs can be very effective but tend to cause more severe side effects than newer antidepressants, like SSRIs. They increase levels of norepinephrine and serotonin and block the action of acetylcholine, another neurotransmitter.
• Monoamine oxidase inhibitors (MAOIs): These drugs may be prescribed when others haven’t worked. They’re rarely first-line treatments because they can have serious side effects and require avoidance of certain foods and other drugs, which can cause dangerous or even deadly interactions. An enzyme called monoamine oxidase helps remove neurotransmitters norepinephrine, serotonin and dopamine from the brain. MAOIs prevent this from happening, making more of these brain chemicals available to effect changes in brain cells and circuits.
• Atypical antidepressants: These don’t fit into other classes of antidepressants, but each still works in its own way to affect neurotransmitters used to communicate between brain cells. 
• Other medications: Your physician may recommend adding mood stabilizers, anti-anxiety or anti-psychotic drugs to enhance the effects of your antidepressant. 

Psychotherapy

Also known as talk therapy or psychological therapy, this involves talking about your condition, symptoms, mental health history and life with a mental or behavioral health professional. This type of therapy can help you find effective coping mechanisms, replace negative beliefs and behaviors with positive ones, set realistic goals, develop health problem-solving strategies, identify triggering issues in your lifestyle or relationships, and regain a sense of control or satisfaction in your life.

Other Treatment Options

• Electroconvulsive therapy (ECT): Usually reserved for people who don’t improve with medication or can’t take antidepressants, this therapy involves electrical currents passed through the brain to impact the function and effects of neurotransmitters.

Complications

Major depressive disorder can get worse if it’s not treated, leading to problems that can affect a person’s emotions, physical health, social life, occupation and daily functioning. Examples of these complications include:

Alcohol or drug abuse: These can have negative effects on physical health, safety and relationships.

Excess weight gain or malnutrition: Overeating or undereating puts a person at risk for a variety of health conditions. 

Other psychological issues: These may include anxiety, panic disorders or social phobias.

Self-mutilation: Some people with major depressive disorder turn to self-harm, like cutting, as a very dangerous and destructive coping mechanism.

Social distress or isolation: This may lead to conflicts with family and friends, problems at work or school, and deeper depression. 

Suicidal feelings: These can lead to suicide attempts or actual suicide.

What must be present for someone diagnosed with major depressive disorder?

What are 4 criteria used to diagnose depression?