Major Depression

Depression – Major; Unipolar Depression; Major Depressive Disorder

Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods.

True clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for a long period of time.

Causes, Incidence, and Risk Factors

The exact cause of depression is not known. Many researchers believe it is caused by chemical imbalances in the brain, which may be hereditary or caused by events in a person’s life.

Some types of depression seem to run in families, but depression can also occur in people who have no family history of the illness. Stressful life changes or events can trigger depression in some people. Usually, a combination of factors is involved.

Men and women of all ages, races, and economic levels can have depression. Depression can also occur in children and teenagers.

A number of factors can play a role in depression:

  • Alcohol or drug abuse
  • Life events or situations, such as:
    • Breaking up with a boyfriend or girlfriend, failing a class, illness or death in the family, or parents divorcing (for adolescents)
    • Childhood events, such as abuse or neglect
    • Divorce, death of a friend or relative, or loss of a job (for adults)
    • Social isolation (common in the elderly)
  • Medical conditions such as hypothyroidism (under-active thyroid), medications (such as sedatives and high blood pressure medications), cancer, major illness, or prolonged pain
  • Sleeping problems

Depression can change or distort the way adolescents see themselves and their lives, as well as other people around them. People who have depression usually see everything with a more negative attitude, unable to imagine that any problem or situation can be solved in a positive way.

Symptoms include:

  • Agitation, restlessness, and irritability
  • Dramatic change in appetite, often with weight gain or loss
  • Extreme difficulty concentrating
  • Fatigue and lack of energy
  • Feelings of hopelessness and helplessness
  • Feelings of worthlessness, self-hate, and inappropriate guilt
  • Inactivity and withdrawal from usual activities, a loss of interest or pleasure in activities that were once enjoyed (such as sex)
  • Thoughts of death or suicide
  • Trouble sleeping or excessive sleeping

Depression can appear as anger and discouragement, rather than as feelings of hopelessness and helplessness. Use of alcohol or illegal substances may be more likely to occur.

If depression is very severe, there may also be psychotic symptoms, such as hallucinations and delusions. These symptoms may focus on themes of guilt, inadequacy, or disease.

Signs and Tests

Major depression is diagnosed if a person reports having five or more depressive symptoms for at least 2 weeks. Beck’s Depression Scale Inventory or other screening tests for depression can be helpful in making the diagnosis.

Before diagnosing depression, the health care provider should rule out medical conditions that can cause symptoms of depression.


Medicines that you take for other problems could cause or worsen depression. You may need to change them. DO NOT change or stop taking any of your medications without consulting your doctor.

People who are so severely depressed that they are unable to function, or who are suicidal and cannot be safely cared for in the community may need to be treated in a psychiatric hospital.

Most people benefit from antidepressant drug therapy, along with psychotherapy. As treatment takes effect, negative thinking diminishes. It takes time to feel better, but there are usually day-today improvements.

Medications for Depression

Drugs used to treat depression are called antidepressants.

  • Selective serotonin re-uptake inhibitors (SSRIs) are the most commonly used antidepressants. Names include: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).
  • Serotonin norepinephrine reuptake inhibitors (SNRIs) are also commonly used. Names include desvenlafaxine (Pristiq), venlafaxine (Effexor), and duloxetine (Cymbalta).
  • Other medicines used to treat depression include: tricyclic antidepressants, bupropion (Wellbutrin), and monoamine oxidase inhibitors.
  • People with psychotic symptoms, such as delusions or hallucinations, may need antipsychotic medications.

Some people with major depression may feel better after taking antidepressants for a few weeks. However, many people need to take medication for 4 – 9 months to get a full response and to prevent depression from coming back.

Some people who do not improve with routine dosages of antidepressants and talk therapy have what is called treatment-resistant depression. They are often prescribed higher (but still safe) doses of their antidepressants, or a combination of medications. Lithium and thyroid hormone supplements also may be added to help the antidepressants work better.

Women being treated for depression who are pregnant or thinking about becoming pregnant should not stop taking antidepressants without first talking to their doctors.

An over-the-counter herb called St. John’s wort may help some people with mild depression only. It can change the way other medicines work in your body, including antidepressants and birth control pills. Always talk to your doctor before trying this herb.

Note: Young adults ages 18 – 24 should be watched more closely for suicidal behavior, especially during the first few months after starting medications.

Talk Therapy

People with depression benefit from some type of talk therapy and counseling. Talk therapy is a good place to talk about feelings and thoughts, and most importantly, learn ways to deal with them.

Types of talk therapy include:

  • Cognitive behavioral therapy teaches depressed people ways of fighting negative thoughts. People can learn to be more aware of their symptoms, learn what seems to make depression worse, and learn problem-solving skills.
  • Psychotherapy can help someone with depression understand the issues that may be behind their behaviors, thoughts, and feelings.
  • Joining a support group of people who are experiencing problems like yours can also help. Ask your therapist or doctor for a recommendation.
Other Therapies

Electroconvulsive therapy (ECT) may improve the mood of severely depressed or suicidal people who don’t respond to other treatments. It may also help with depressed patients who have psychotic symptoms.

Transcranial magnetic stimulation (TMS) uses high frequency magnetic pulses that target affected areas of the brain. It is often thought to be a second-line treatment after ECT.

Use of light therapy for depressive symptoms may help in the winter months to restore a normal sleep cycle. However, by itself it is not an effective treatment for major depression.

Expectations (Prognosis)

The outcome with treatment is usually good, but not for everyone. Depression is a recurring problem for many people.

For people who have repeated episodes of depression, quick and ongoing treatment may be needed to prevent more severe, long-term depression. Sometimes people will need to stay on medications for long periods of time.

  • Alcohol- and drug-related problems, as well as tobacco dependence are more likely in people with long-term depression
  • Increased risk of problems with physical health and premature death due to medical illness
  • Suicide (up to 15% of people with major depressive disorder die by suicide)
Calling Your Health Care Provider

Call 911, a suicide hotline, or get safely to a nearby emergency room if you have thoughts of
suicide, a suicidal plan, thoughts of harming yourself or others, or other suicide warning signs.

There are numbers you can call from anywhere in the United States, 24 hours a day, 7 days a
week: 1-800-SUICIDE or 1-800-999-9999.

Call your doctor right away if:

  • You hear voices that are not there.
  • You have frequent crying spells with little or no provocation.
  • Your depression is disrupting work, school, or family life.
  • You think that your current medications are not working or are causing side effects. DO
    NOT change or stop any medications without consulting your doctor.
  • You believe that you should cut back on drinking, a family member or friend has asked
    you to cut back, you feel guilty about the amount of alcohol you drink, or you drink
    alcohol first thing in the morning

To better manage your depression at home:

  • Take medications correctly and learn how to manage side effects.
  • Learn to watch for early signs that depression is becoming worse and know how to react when it does.
  • Try to exercise more, seek out other activities that bring you pleasure, and maintain good sleep habits.
  • Avoid alcohol and illegal drugs. These substances can make the depression worse over time, and may also impair your judgment about suicide.
  • When struggling with your depression, talk to someone you trust about how you are feeling. Try to be around people who are caring and positive.
  • Try volunteering or getting involved in group activities.
  1. Fava M, Cassano P. Mood disorders: Major depressive disorder and dysthymic disorder. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusette General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 29.
  2. American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder. 2nd ed. September 2007. Accessed January 22, 2010.
  3. Little A. Treatment-resistant depression. Am Fam Physician. 2009;80:167-172. [PubMed]

Review Date: 2/14/2010.

Reviewed by: Paul K. Berger, MD, Addiction and Forensic Psychiatrist, Scripps Memorial Hospital, La Jolla, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Copyright © 2011, A.D.A.M., Inc.