Are You Simply Sad or Do You Have Major Depressive Disorder?

Do you struggle to get out of bed most mornings? Is just the thought of getting dressed exhausting? Is it less and less fun to spend time with friends and family? Do you find yourself eating a lot more or a lot less than usual?

Many people think that being depressed simply means feeling really, really sad. Yet you don’t have to be teary to be depressed. All of the behaviors above — and a myriad of others that affect how you think, feel, behave, and express yourself — can be signs of depression.

In fact, depression is one the most common illnesses worldwide, according to the World Health Organization.  In the United States alone it affects an estimated 17.3 million adults ages 18 and older (8.7 percent of women and 5.3 percent of men) as well as an estimated 3.2 million adolescents ages 12 to 17 (13.3 percent), per the National Institute of Mental Health (NIMH).

How Do You Know It’s Major Depressive Disorder?

You’ve probably heard the word “depression” tossed around to describe normal everyday dips in mood, things like “This haircut made me so depressed” or “That movie was so sad, I’m depressed.” But when you are actually depressed, “You’re not just blue or down in the dumps,” says clinical psychologist Lorna Gale Cheifetz, PsyD. “You’re really not functioning.”

In fact, to be diagnosed with major depressive disorder — sometimes called clinical depression or simply depression, or by its abbreviation, MDD — you have to experience several distinct symptoms for most of the day, nearly every day, for at least two weeks.

One of those symptoms needs to be persistent feelings of sadness or emptiness, or a loss of interest in activities you used to enjoy, such as work, hobbies, seeing friends — even food and sex.

According to the American Psychiatric Association’s current Diagnostic and Statistical Manual of Mental Disorders (DSM-5), you also need to experience at least four of the following symptoms (or three if you have both of the symptoms above):

  • Significant changes in appetite — weight loss or gain not related to dieting
  • Trouble sleeping (insomnia) or sleeping too much (hypersomnia)
  • Increased restlessness (called psychomotor agitation) or the opposite, moving more slowly (called psychomotor retardation)
  • Fatigue, tiredness, or loss of energy, making even simple tasks, such as dressing or washing, difficult
  • Feeling worthless or inappropriately guilty, such as constantly thinking about past mistakes
  • Difficulty thinking clearly, concentrating, or making decisions
  • Recurrent thoughts of death or suicide (without or without a specific plan), or a suicide attempt

It’s important to note that to count toward a diagnosis of major depressive disorder, a symptom must cause significant distress or make everyday tasks much harder than usual. So, for example, if you normally have trouble falling asleep, insomnia wouldn’t count as a symptom of major depression for you.

When Is It Not Major Depressive Disorder?

If you have some of the symptoms above, but not enough of them, or they’re not severe enough to meet the criteria for MDD, you might have persistent depressive disorder (PDD), the DSM-5’s new name for what was previously called dysthymia.

PDD symptoms are similar to MDD symptoms — sleep problems, low energy, low self-esteem, difficulty concentrating, poor appetite, and feelings of hopelessness — but they’re milder and they’re chronic: You can generally function, just not at your best.

To meet the criteria for PDD, your mood needs to be low and you must have at least two other symptoms for two years or more.

It’s also possible to have something called “double depression,” in which PDD evolves into MDD (typically provoked by a triggering event, such as losing a job or failing to achieve an important goal) then reverts back to PDD. Although not well known, double depression affects 75 percent of people with PDD at some point, according to the National Alliance on Mental Illness.

You can even feel depressed and not have a mood disorder at all. That’s because symptoms of many other medical conditions, including anemia, thyroid problems, Lyme disease, Parkinson’s disease, and pancreatic cancer, can masquerade as depression.

Making matters more confusing, your medication could be to blame. A University of Illinois at Chicago College of Pharmacy study, published in June 2018 in The Journal of the American Medical Association, estimated that 33 percent of U.S. adults may be using one or more prescription drugs that can cause side effects that mimic depression, including thoughts of suicide. These include oral contraceptives, as well as certain treatments for high blood pressure, high cholesterol, acid reflux, and severe acne.

“Patients and healthcare providers need to be aware of the risk of depression that comes with all kinds of common prescription drugs — many of which are also available over the counter,” notes Dima Mazen Qato, PharmD, PhD, assistant professor in the Department of Pharmacy Systems, Outcomes, and Policy at The University of Illinois at Chicago and lead author of the study.

“Many may be surprised to learn that their medication, despite having nothing to do with mood or anxiety or any other condition normally associated with depression, can increase their risk of experiencing depressive symptoms, and may lead to a depression diagnosis.”

What Are the Roots of Depression?

There’s broad agreement among mental health professionals and researchers that depression is primarily caused by three kinds of factors that interact to varying degrees in each patient: biological (including your genes, your hormones, and your physical health), psychological (such as your coping skills and how you view yourself), and social (like early life events or prolonged stress at work or home).

Recent research also points to the importance of the health of the gut’s microbiome, the “good” bacteria the keep your digestive tract functioning at its best. A healthy microbiome appears to play an essential role in the release of hormones and mood-lifting brain chemicals, according to an article published February 2019 in Science magazine.

Barriers to Treatment: Not Everyone Gets the Help They Need

Major depression is very treatable, especially when the approach is tailored to an individual’s body and lifestyle. Yet approximately 35 percent of adults and 60 percent of adolescents who have it don’t receive any treatment.

This is worrisome given that depression raises the risk of many other illnesses, including heart disease, diabetes, stroke, and Alzheimer’s disease, and has been linked to substance abuse.

Depression also increases the risk of suicide, the 10th leading cause of death in the United States, according to the NIMH.

Reasons for not getting treatment vary. “A lot of people suffer in silence because we don’t yet live in a culture where it’s easy to talk authentically about it,” says psychotherapist Hilary Jacobs Hendel, a licensed clinical social worker and author of It’s Not Always Depression: Working the Change Triangle to Listen to the Body, Discover Core Emotions, and Connect to Your Authentic Self. “People feel a lot of shame and guilt.”

Another reason is that depression encourages the belief that nothing could ever be of help. As journalist Susan Cheng explained in an essay she wrote about her depression, “Sometimes you fight back, but most days you just sit there in quiet resignation, trying your best to breathe. And because the illness is a part of you, engrained so deeply in your being, you start to believe that this is just how everyone must feel.”

A key barrier is also cost of care. Having inadequate insurance or no coverage can make the cost of prescription drugs and psychotherapy prohibitive. Poverty doubles the likelihood that a person may experience major depression, yet that same factor makes it harder to access treatment. (11) Fortunately, a few low-cost options exist, including:

  • Teaching hospitals and universities with training programs in psychiatry and psychology, which often offer low-cost psychotherapy provided by trainees supervised by senior staff
  • The Medicine Assistance Tool from the Pharmaceutical Research and Manufacturers of America, which connects to a database of hundreds of public and private programs that provide eligible patients with prescription drugs at a discount or for free
  • Retailers, including Walmart, Walgreens, and Rite Aid, selling several frequently prescribed generic drugs for as little as $4


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