Symptoms and Approaches to Major Depression
- Victoria Wermers, RN,MSN,FNP, PMHNP
- Nov 11, 2024
- 12 min read
Updated: Aug 4
Major Depression - Persistent Depressive Disorder (PDD)
Once in a while, sadness leads you to this place where your emotions take over reasoning. And, sometimes, when it is not caused by a particular situation, you have no idea how you got here.
So, here you are. How did you get to this point?
The following discusses major depression, signs, symptoms, and treatment options. There is also a brief mention of persistent depressive disorder (PDD) - Dysthymia, an ongoing low level of depression that lacks some of the severe symptoms of major depression.
Symptoms and Approaches to Major Depression:
Symptoms of Major Depression
In most cases, major depression is not caused by a single incident. UpToDate cites the DSM V criteria for this diagnosis: A person must have five or more of the following symptoms most of the day or nearly every other day for at least two weeks (often the time frames overlap in different depressive disorders). One symptom MUST include either depressed mood or loss of interest or pleasure:
Persistently low or depressed mood
Decreased interest in usually pleasurable activities (anhedonia),
Feelings of guilt or worthlessness.
Poor concentration.
Appetite and weight changes,
Psychomotor retardation (like sluggish speech, OR agitation (restlessness, agitation),
Poor concentration
Sleep disturbances (too little or too much),
Suicidal thoughts or thoughts of death (need help suicide prevention hotline (1-800-273-TALK ).
Lack of energy/fatigue almost every day
Sad, anxious, or empty mood, hopeless feelings
In addition to the five+, depressive symptoms above, major depression must be accompanied by impaired social or work activities, not due to substance or medical problems, and cannot be accompanied by other serious mental health problems like schizophrenia, psychotic symptoms, or manic behaviors.
Major depression can be accompanied by other things. It often presents with anxiety. After all, wouldn't debilitating depression make a person anxious, and wouldn't anxiety make depression worse?. And sometimes there is concomitant pain: Imagined or real. Depression can be intensified by coexisting social, psychological, and/or medical problems, some of which are discussed in other sections.
Major depression likes to take over rational thought. It hijacks your brain by taking over normal neurotransmitter actions, subsequently causing changes in the gray matter of your brain.
Without treatment, major depression can usually last for several weeks, sometimes months (usually six months), and even years. According to the NIH, “the recurrence rate is about 50% after the first episode, 70% after the second episode, and 90% after the third”.
The PHQ-9 is a simple depression rating scale used by many mental health professionals to determine how bad a person's depression is. It is also used to measure progress when a person is being treated.
Approaches to Helping Major Depression
General Approaches
Reduce stress
Exercise or walk
Try techniques such as yoga or tai chi
Meditation and relaxation exercises:
-Deep breathing exercises - This helps release endorphins in your brain, which are"feel good" hormones. This technique is practiced by taking a deep breath through your mouth using your diaphragm muscle located just beneath your lower ribs (instead of using neck, shoulder and upper chest muscles), pausing and then releasing the breath through the mouth. Repeat this several times.
-Guided Imagery - Think of a relaxing situation or a place you have been and focus on only that - focusing on texture, smells and visuals.
-Use Mindfulness - This is when a person focuses on the present moment, feeling and experiencing the moment with awareness and acceptance, not judgment. This reportedly helps the fronto-limbic area of the brain, which is responsible, in great part, for emotional regulation and processing.
-Progressive Muscle Relaxation Exercises: This is done by tightening muscle groups for eight seconds then relaxing them for several seconds: Begin with facial muscles, with the face, moving to the scalp - tighten muscles eight seconds, then relax; then the neck, doing with each muscle group of the chest, back, pelvis, extremities and so on. This releases some tension and stress. If you do not have time to move through all of your muscle groups, do this with those muscles you believe have the most tension.
-Analytical Meditation - This meditation involves focusing on an object or a concept and focusing on only that.
-Body Scanning - Focus on a part of your body and feel relaxation, warmth, and release of tension.
-Reiki is a practice whereby a person connects with a universal positive energy. There are quite a few online sources with free instructions; additionally, many instructors also teach these methods in person.
Journal: Write your thoughts in a journal
Talk to someone about your problem - friends, family: Don't worry, people who care about you are commonly concerned and want to help
Practice affirmations - saying good things about yourself
Set realistic goals and work toward them
Listen to good music
Recognize and celebrate even small successes
Humor therapy - laugh or just make yourself smile (usually used as an adjunct to other therapies).
Light therapy - May help non-seasonal depression in conjunction with serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).
For some people, spirituality can contribute to a deeper sense of control, purpose, hope, optimism, peace and connection; potentially improving overall health and well-being
Massage
Counseling often helps: Sometimes, just being able to talk to someone helps more than you know. The best therapies all have one common bond: establishing a trusting relationship. If a counselor is good, they can work with you on different ways to cope and provide therapy that will suit your needs. Some of the more popular of these are mentioned in the following:
Therapies and Other Treatments for Depression
Cognitive Behavioral Therapy (CBT) - This is currently considered one of the best, if not the best, forms of therapy. There are several subtypes of CBTs, but they all work on the same premise: to help recognize and challenge dysfunctional thought patterns that underly a person's depression.
CBT is a way in which people promote neuroplasticity to improve. Through this kind of therapy, neurons can be trained to send impulses down different, new pathways instead of using the old negative pathways. The brain changes and adapts by forming new neural connections (or strengthening existing "good" ones) based on purposeful learning, recitation, and practicing more constructive thought patterns and positive experiences: Essentially "rewiring". This implies that you can train your brain to think differently and more positively. It makes sense.
Types of CBT:
-Cognitive Restructuring - Cognitive restructuring can help a person change their way of thinking about a situation. Using this therapy, a person learns to identify and challenge negative or irrational thought patterns and develop new patterns of thinking.
-Dialectic Behavioral Therapy (DBT) - Similar to CBT, but with DBT a person works on validating or accepting uncomfortable thoughts, feelings, and behaviors instead of fighting them.
-Mindfulness-Based Stress Reduction Therapy (MBSR) - Helps people change their response to depressing and intrusive thoughts.
-Motivational Interviewing (MI) helps people identify positive goals and factors that might motivate them to work toward those goals.
-Acceptance and Commitment Therapy (ACT) - This also helps direct a person to accept feelings and develop some tolerance to those feelings through the use of new coping mechanisms.
Note: CBT is also effective for those with other mental health problems.
Psychoanalysis is an interpersonal therapy that delves into a person's past, exploring possible roots of depression and working through the thoughts and feelings. It aims to help a person develop alternative, more effective coping mechanisms.
Eye Movement Desensitization and Reprocessing (EMDR) - This therapeutic technique deals with traumatic memories and, in this case, depression due to trauma. The therapist guides the client to focus their eyes on an object as it moves repetitively from side to side. At the same time, they process through the negative traumatic memories and transition to positive ones. This is effective for many people. This treatment entails "rewiring" of the brain.
Transcranial Magnetic Stimulation (TMS) This treatment is sometimes used when other conventional treatments have not worked. An electrical coil is placed on your scalp, through which electrical stimulation occurs. Current is sent to the area of the brain responsible for mood/depression, which results in "rewiring" of that area. Transcranial Magnetic Stimulation (TMS)
TMS is typically well tolerated, usually with little or no discomfort. It is often given as an adjunct to medication. Interestingly, some of these devices are available online but the electrical charge is lower, so they may not be as effective as those at a clinic and their safety cannot be assured (not FDA approved). I'm not sure I would go this route.
TMS is a time-consuming therapy. Treatments are, on average, 30 minutes long, five times a week for about six weeks (this is variable). According to PubMed, about 36% of people experience improvement (many other resources say more), and sometimes a relapse occurs, but a person can undergo more than one course.
Electroconvulsive Therapy (ECT) is often portrayed as an intrusive maniacal treatment straight out of One Flew OVER the Cuckoo's Nest. But the fact is that it can work as a last resort when therapy and medication are not working. It is another type of electrical stimulation to the brain, more powerful than TMS, eliciting a small seizure under general anesthesia. The remission rate is higher than 50% and is best used in conjunction with and followed by antidepressant medications to avoid relapse, which can occur.
Immediately after the procedure, there may be some brief disorientation, nausea, headaches, fatigue, muscle aches, and a brief episode of memory loss, but this usually passes quickly. Very occasionally, some of these side effects last days to weeks, maybe longer. The question is, do the benefits outweigh the risks? For a person with severe depression, they may.
Over-the-Counter Medications
There are no reliable over-the-counter medications that treat major depression. You can try to do it by lifestyle changes, like getting enough sleep, eating a truly nutritional diet, and taking multivitamins (especially B12). While those things may support your health, and to a small degree your mood, they are not reliable avenues to treating major depression.
Considered Natural and Herbal Remedies
DHEA (dehydroepiandrosterone) is a substance produced by the adrenal gland. It is a prohormone or precursor to certain hormones including estrogen and progesterone (among others). It also has neuroprotective effects and increases serotonin and dopamine levels in the brain. It has some medication interactions and quite a few potentially unwanted side effects however may help with depression. As a mood enhancer in depression, DHEA usually takes up to six months for optimal effects Because it does increase estrogen, there is a potential risk of taking in those who have hormone-receptive cancer.
Omega 3 - Fish oil/krill oil - has a lot of beneficial properties for the brain (and possibly for depression): Decreases inflammation of the brain tissue, thereby protecting neurons from damaging effects. It reportedly has neuroplasticity benefits, and because it enhances communication between neurons, it promotes neuroplasticity. In general, Omega-3 protects the gray matter and white matter of the brain from some degeneration.
Omega 3s can take up to six months to work, so you may want to use it to supplement a prescription antidepressant medication.
Prescriptive Medications for the Treatment of Depression
In general, medication works better when given as an adjunct to counseling. However, if a person really doesn't want to engage in counseling, just taking medication is better than nothing.
Regarding medication: Some people are concerned about not being able to "feel" their emotions when taking an antidepressant. This is called "blunting" and is a reason why patients sometimes come off their medications. It is important that you speak to the person prescribing the medication if you feel this is occurring (there are many types of medications for depression on the market, and with these, it's like a shoe that fits. You sometimes have to try on several before you find the one that fits the best. In some cases, there is no such shoe; in which case, you may want or need to try some of the other approaches discussed here.
SSRIs (serotonin reuptake inhibitors) and SNRIs (serotonin and norepinephrine reuptake inhibitors) are widely used antidepressants. These medications increase concentrations of the neurotransmitters in the brain responsible for elevating a person's mood: Serotonin, dopamine, and norepinephrine in the brain. These neurotransmitters are responsible for elevating a person's mood. Common antidepressant medications here include escitalopram (Lexapro), citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), and vilazodone (Viibryd).
Tricyclic Antidepressants also increase levels of available neurotransmitters, serotonin and norepinephrine. The best-known of these is Amitriptyline (Elavil). Because of their propensity for side effects, they are not prescribed as much as the SSRIs and SNRIs mentioned above. Sometimes tricyclics are also used off-label to help decrease neuropathic pain.
MAO inhibitors are the oldest class of antidepressants, developed in the 1950s. They have a lot of interactions with foods, drinks, other medications and herbs so these are not used a lot anymore.
Lithium is occasionally used off-label (that is, not approved for depression by the FDA) in treatment-resistant depression when other means fail but people need to be closely monitored for side effects and lithium levels need to be monitored.
Some newer potential treatments are in the early stages of testing and development. Interestingly, some good results with depression are coming from these but, since they are known as illicit drugs, they are controversial. These include:
Ketamine (esketamine) was originally used as an anesthetic during the Vietnam War and has been used for that purpose ever since. It is a relatively new off-label approach to treatment-resistant depression. The benefit of ketamine is that, if it is going to work for depression (about 50%), it works fast, within two to four hours, and the effects last for several days. So if there is a person with severe acute depression and suicidality, this may help. The downside is that it can cause some psychiatric/dissociative (i.e. disconnectedness, hallucinations) characteristics and also has the potential for addiction, and it should not be used by people with substance abuse issues.
Exactly how ketamine works in the brain is not yet clear. There are several theories; the primary premise is that Ketamine decreases glutamate (an excitatory neurotransmitter) and increases GABA (a "calming" neurotransmitter) activity in the brain. This essentially repairs and enhances neurotransmission in the prefrontal cortex, in turn, reducing depression. Because it works on different brain receptors than SSIs and SNRIs, it may be a good option when a person does not respond to conventional antidepressants. Ketamine is also considered an adjunct in creating greater neuroplasticity-helping to create new neuronal channels, transformational in depressive thinking patterns.
There are other theories that are far beyond the scope of this site. For more detailed information, see the NIH publication: Ketamine Treatment for Depression: A Review. There is a good deal of ongoing research and emerging information on Ketamine. It is approved by the FDA for the treatment of major depression. For those interested (especially for those who cannot afford it), there are clinical trials in several states.
Ketamine (esketamine) is a controlled substance. It is given under close monitoring in a ketamine clinic or, in some cases, at home. It is administered intravenously or intranasally (Spravato). While dosing is different for many people, it is generally given three to six times over the course of a few weeks.
Psilocybin mushrooms are another novel approach to treatment-resistant depression. It is similar to ketamine in that it enhances the effects of neurotransmitters and neuroplasticity. These rapidly produce a reduction in depressive symptoms almost immediately, and the antidepressant effects last for several weeks, sometimes even longer. More research is currently being done on psilocybin and depression, and although it has been shown to decrease depression in many people, it has not been approved by the FDA for the treatment of depression.
Because of some of the potential side effects of psilocybin (sometimes anxiety, confusion, paranoia, and others), it is not for everyone, and because of the hallucinations and the "high" some people feel it is considered an "illicit drug". When used for depression, counseling is used as an adjunct. It is administered under controlled conditions, and the only clinics where it is administered at this time are in Oregon (as of November 2024). Colorado is reportedly planning to open psilocybin clinics in 2025.
Hopefully, the above symptoms and approaches to major depression will help you understand depression and the many strategies that can be used to help deal with it successfully. If one does not work, try another. If you believe you are depressed, you need to do something about it ; otherwise you just remain your old "dumpy" self. The answer rarely comes to you; you need to seek it out.
If you are suffering from depression, contact someone - a counselor, a friend, or a family member.
If you are considering suicide, call 911 - you can talk, text, or chat. You can also access this site on your PC.
Read this closely: The real reason for not committing suicide is because you always know how swell life gets again after the hell is over - Hemingway
A Note About Persistent Depressive Disorder (PDD) (Dysthymia)
PDD is just what it says: It is persistent. Unlike major depression, which usually lasts around six to 12 months, this depression is usually a low-grade depression that goes on and on, present almost every day, and lasts for more than two years. The symptoms are like those of major depression (above) but do not include anhedonia (inability to feel pleasure) and psychomotor symptoms like lethargy or agitation. Overall, symptoms are usually less extreme; however, they can still interfere with various areas of a person’s functioning, for instance, their socialization skills, ability to maintain work and family responsibilities, and even activities of daily living such as regular hygiene practices like bathing or changing clothes
The underlying physiologic brain patterns in PDD suggest an imbalance of neurotransmitters serotonin, epinephrine, norepinephrine, and glutamate, and changes in some brain structures (orbitofrontal cortex and hippocampus). Why does this occur? It can be caused by many of the same things that cause major depression (genetics, environment, trauma, and other factors).
Treatment approaches are similar to those mentioned above for major depression.
