presentations on depression

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• What is depression? A Mayo Clinic expert explains.

Learn more about depression from Craig Sawchuk, Ph.D., L.P., clinical psychologist at Mayo Clinic.

Hi, I'm Dr. Craig Sawchuk, a clinical psychologist at Mayo Clinic. And I'm here to talk with you about depression. Whether you're looking for answers for yourself, a friend, or loved one, understanding the basics of depression can help you take the next step.

Depression is a mood disorder that causes feelings of sadness that won't go away. Unfortunately, there's a lot of stigma around depression. Depression isn't a weakness or a character flaw. It's not about being in a bad mood, and people who experience depression can't just snap out of it. Depression is a common, serious, and treatable condition. If you're experiencing depression, you're not alone. It honestly affects people of all ages and races and biological sexes, income levels and educational backgrounds. Approximately one in six people will experience a major depressive episode at some point in their lifetime, while up to 16 million adults each year suffer from clinical depression. There are many types of symptoms that make up depression. Emotionally, you may feel sad or down or irritable or even apathetic. Physically, the body really slows down. You feel tired. Your sleep is often disrupted. It's really hard to get yourself motivated. Your thinking also changes. It can just be hard to concentrate. Your thoughts tend to be much more negative. You can be really hard on yourself, feel hopeless and helpless about things. And even in some cases, have thoughts of not wanting to live. Behaviorally, you just want to pull back and withdraw from others, activities, and day-to-day responsibilities. These symptoms all work together to keep you trapped in a cycle of depression. Symptoms of depression are different for everyone. Some symptoms may be a sign of another disorder or medical condition. That's why it's important to get an accurate diagnosis.

While there's no single cause of depression, most experts believe there's a combination of biological, social, and psychological factors that contribute to depression risk. Biologically, we think about genetics or a family history of depression, health conditions such as diabetes, heart disease or thyroid disorders, and even hormonal changes that happen over the lifespan, such as pregnancy and menopause. Changes in brain chemistry, especially disruptions in neurotransmitters like serotonin, that play an important role in regulating many bodily functions, including mood, sleep, and appetite, are thought to play a particularly important role in depression. Socially stressful and traumatic life events, limited access to resources such as food, housing, and health care, and a lack of social support all contribute to depression risk. Psychologically, we think of how negative thoughts and problematic coping behaviors, such as avoidance and substance use, increase our vulnerability to depression.

The good news is that treatment helps. Effective treatments for depression exist and you do have options to see what works best for you. Lifestyle changes that improve sleep habits, exercise, and address underlying health conditions can be an important first step. Medications such as antidepressants can be helpful in alleviating depressive symptoms. Therapy, especially cognitive behavioral therapy, teaches skills to better manage negative thoughts and improve coping behaviors to help break you out of cycles of depression. Whatever the cause, remember that depression is not your fault and it can be treated.

To help diagnose depression, your health care provider may use a physical exam, lab tests, or a mental health evaluation. These results will help identify various treatment options that best fit your situation.

Help is available. You don't have to deal with depression by yourself. Take the next step and reach out. If you're hesitant to talk to a health care provider, talk to a friend or loved one about how to get help. Living with depression isn't easy and you're not alone in your struggles. Always remember that effective treatments and supports are available to help you start feeling better. Want to learn more about depression? Visit mayoclinic.org. Do take care.

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and sometimes you may feel as if life isn't worth living.

More than just a bout of the blues, depression isn't a weakness and you can't simply "snap out" of it. Depression may require long-term treatment. But don't get discouraged. Most people with depression feel better with medication, psychotherapy or both.

Depression care at Mayo Clinic

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Although depression may occur only once during your life, people typically have multiple episodes. During these episodes, symptoms occur most of the day, nearly every day and may include:

• Feelings of sadness, tearfulness, emptiness or hopelessness
• Angry outbursts, irritability or frustration, even over small matters
• Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports
• Sleep disturbances, including insomnia or sleeping too much
• Tiredness and lack of energy, so even small tasks take extra effort
• Reduced appetite and weight loss or increased cravings for food and weight gain
• Anxiety, agitation or restlessness
• Slowed thinking, speaking or body movements
• Feelings of worthlessness or guilt, fixating on past failures or self-blame
• Trouble thinking, concentrating, making decisions and remembering things
• Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide
• Unexplained physical problems, such as back pain or headaches

For many people with depression, symptoms usually are severe enough to cause noticeable problems in day-to-day activities, such as work, school, social activities or relationships with others. Some people may feel generally miserable or unhappy without really knowing why.

Depression symptoms in children and teens

Common signs and symptoms of depression in children and teenagers are similar to those of adults, but there can be some differences.

• In younger children, symptoms of depression may include sadness, irritability, clinginess, worry, aches and pains, refusing to go to school, or being underweight.
• In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feeling misunderstood and extremely sensitive, using recreational drugs or alcohol, eating or sleeping too much, self-harm, loss of interest in normal activities, and avoidance of social interaction.

Depression symptoms in older adults

Depression is not a normal part of growing older, and it should never be taken lightly. Unfortunately, depression often goes undiagnosed and untreated in older adults, and they may feel reluctant to seek help. Symptoms of depression may be different or less obvious in older adults, such as:

• Memory difficulties or personality changes
• Physical aches or pain
• Fatigue, loss of appetite, sleep problems or loss of interest in sex — not caused by a medical condition or medication
• Often wanting to stay at home, rather than going out to socialize or doing new things
• Suicidal thinking or feelings, especially in older men

When to see a doctor

If you feel depressed, make an appointment to see your doctor or mental health professional as soon as you can. If you're reluctant to seek treatment, talk to a friend or loved one, any health care professional, a faith leader, or someone else you trust.

When to get emergency help

If you think you may hurt yourself or attempt suicide, call 911 in the U.S. or your local emergency number immediately.

Also consider these options if you're having suicidal thoughts:

• Call your doctor or mental health professional.
• Contact a suicide hotline.
• In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential.
• U.S. veterans or service members who are in crisis can call 988 and then press “1” for the Veterans Crisis Line . Or text 838255. Or chat online .
• The Suicide & Crisis Lifeline in the U.S. has a Spanish language phone line at 1-888-628-9454 (toll-free).
• Reach out to a close friend or loved one.
• Contact a minister, spiritual leader or someone else in your faith community.

If you have a loved one who is in danger of suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

More Information

Depression (major depressive disorder) care at Mayo Clinic

• Male depression: Understanding the issues
• Nervous breakdown: What does it mean?
• Pain and depression: Is there a link?

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It's not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, such as:

• Biological differences. People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.
• Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.
• Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression. Hormone changes can result with pregnancy and during the weeks or months after delivery (postpartum) and from thyroid problems, menopause or a number of other conditions.
• Inherited traits. Depression is more common in people whose blood relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.
• Marijuana and depression
• Vitamin B-12 and depression

Risk factors

Depression often begins in the teens, 20s or 30s, but it can happen at any age. More women than men are diagnosed with depression, but this may be due in part because women are more likely to seek treatment.

Factors that seem to increase the risk of developing or triggering depression include:

• Certain personality traits, such as low self-esteem and being too dependent, self-critical or pessimistic
• Traumatic or stressful events, such as physical or sexual abuse, the death or loss of a loved one, a difficult relationship, or financial problems
• Blood relatives with a history of depression, bipolar disorder, alcoholism or suicide
• Being lesbian, gay, bisexual or transgender, or having variations in the development of genital organs that aren't clearly male or female (intersex) in an unsupportive situation
• History of other mental health disorders, such as anxiety disorder, eating disorders or post-traumatic stress disorder
• Abuse of alcohol or recreational drugs
• Serious or chronic illness, including cancer, stroke, chronic pain or heart disease
• Certain medications, such as some high blood pressure medications or sleeping pills (talk to your doctor before stopping any medication)

Complications

Depression is a serious disorder that can take a terrible toll on you and your family. Depression often gets worse if it isn't treated, resulting in emotional, behavioral and health problems that affect every area of your life.

Examples of complications associated with depression include:

• Excess weight or obesity, which can lead to heart disease and diabetes
• Pain or physical illness
• Alcohol or drug misuse
• Anxiety, panic disorder or social phobia
• Family conflicts, relationship difficulties, and work or school problems
• Social isolation
• Suicidal feelings, suicide attempts or suicide
• Self-mutilation, such as cutting
• Premature death from medical conditions
• Depression and anxiety: Can I have both?

There's no sure way to prevent depression. However, these strategies may help.

• Take steps to control stress, to increase your resilience and boost your self-esteem.
• Reach out to family and friends, especially in times of crisis, to help you weather rough spells.
• Get treatment at the earliest sign of a problem to help prevent depression from worsening.
• Consider getting long-term maintenance treatment to help prevent a relapse of symptoms.
• Brown AY. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Nov. 17, 2016.
• Research report: Psychiatry and psychology, 2016-2017. Mayo Clinic. http://www.mayo.edu/research/departments-divisions/department-psychiatry-psychology/overview?_ga=1.199925222.939187614.1464371889. Accessed Jan. 23, 2017.
• Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://www.psychiatryonline.org. Accessed Jan. 23, 2017.
• Depression. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/depression/index.shtml. Accessed Jan. 23, 2017.
• Depression. National Alliance on Mental Illness. http://www.nami.org/Learn-More/Mental-Health-Conditions/Depression/Overview. Accessed Jan. 23, 2017.
• Depression: What you need to know. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/depression-what-you-need-to-know/index.shtml. Accessed Jan. 23, 2017.
• What is depression? American Psychiatric Association. https://www.psychiatry.org/patients-families/depression/what-is-depression. Accessed Jan. 23, 2017.
• Depression. NIH Senior Health. https://nihseniorhealth.gov/depression/aboutdepression/01.html. Accessed Jan. 23, 2017.
• Children’s mental health: Anxiety and depression. Centers for Disease Control and Prevention. https://www.cdc.gov/childrensmentalhealth/depression.html#depression. Accessed. Jan. 23, 2017.
• Depression and complementary health approaches: What the science says. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/providers/digest/depression-science. Accessed Jan. 23, 2017.
• Depression. Natural Medicines. https://naturalmedicines.therapeuticresearch.com/databases/medical-conditions/d/depression.aspx. Accessed Jan. 23, 2017.
• Natural medicines in the clinical management of depression. Natural Medicines. http://naturaldatabase.therapeuticresearch.com/ce/CECourse.aspx?cs=naturalstandard&s=ND&pm=5&pc=15-111. Accessed Jan. 23, 2017.
• The road to resilience. American Psychological Association. http://www.apa.org/helpcenter/road-resilience.aspx. Accessed Jan. 23, 2017.
• Simon G, et al. Unipolar depression in adults: Choosing initial treatment. http://www.uptodate.com/home. Accessed Jan. 23, 2017.
• Stewart D, et al. Risks of antidepressants during pregnancy: Selective serotonin reuptake inhibitors (SSRIs). http://www.uptodate.com/home. Accessed Jan. 23, 2017.
• Kimmel MC, et al. Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding. http://www.uptodate.com/home. Accessed Jan. 23, 2017.
• Bipolar and related disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://www.psychiatryonline.org. Accessed Jan. 23, 2017.
• Hirsch M, et al. Monoamine oxidase inhibitors (MAOIs) for treating depressed adults. http://www.uptodate.com/home. Accessed Jan. 24, 2017.
• Hall-Flavin DK (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 31, 2017.
• Krieger CA (expert opinion). Mayo Clinic, Rochester, Minn. Feb. 2, 2017.
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Presentations, Podcasts and Interviews on Depression

Live Presentations on Depression

How to Recover from Depression: Why Skills are Better than Pills

5 million views on youtube.

This one-hour public lecture conducted in Melbourne, Australia was recorded as part of a series of talks sponsored by the Australian Psychological Society (APS). Psychologist and President of the APS, Anthony Cichello began an initiative entitled “Bringing Psychology to the Public” and Michael was honored to present this first talk in the series.

In this presentation Michael shares research and his insights from 40 years of working with those suffering this common mental health issues and specifically depression. Learn the simple skills that research shows can help you or a loved one to recover – and even prevent depression occurring – in this heartwarming and uplifting speech for the Australian Psychological Society.

Depression is Contagious

On October 1, 2013, I was warmly welcomed to a standing room only crowd at The University of Iceland where I spoke on the topic of depression.

The video length is almost an hour and a half (1:24) but you can start and stop the video to be able to watch it in time increments that suit your schedule. The lecture begins in English just before minute 6 in the video. It is my hope that by providing free lectures like this one, I am able to bring relevant information and perspective to people around the world on a major mental health issue affecting millions of people worldwide.

Special thanks to  The University of Iceland, Department of Education  and the  Icelandic Hypnosis Society  for sponsoring this free lecture and filming it so that I could share it with you.

In this conversation with Michael, Nicole Lamberson from the award winning documentary Medicating Normal,  asks Michael to focus on The Non Pharmacological Treatment of Depression.

In this Skype interview for the Inner Voices Show with Dr. Foojan Zeine. Dr. Yapko talks about distinguishing thoughts and feelings that over generalize negativity that leads to producing and/or sustaining Depression.

Audio Interviews and Podcasts on Depression

MindsetHealth.com is a digital therapeutic providing online support for physical and psychological conditions known to benefit from hypnosis.

Current digital hypnotherapy programs in the Mindset Health brand are: CLARIA™   a program for mental health, NERVA™ a program for Irrital Bowel Syndrome (IBS), the EVIA™ program for menopausal symptoms, and FINITO™ program for smoking cessation.

Here are some conversations Michael did with Mindset Health.

RE-THINKING THE TREATMENT OF DEPRESSION: HAVE WE BEEN MISINFORMED ABOUT ANTIDEPRESSANTS?

A conversation with Drs. Michael Yapko and Irving Kirsch facilitated by Claire Davidson of Mindset Health. People have been oversold on the idea about the benefits of antidepressants. This conversation highlights placebo effects and the research that continues to support that depression is not primarily a biological disease that needs to be medicated.

Michael Yapko & Lynn Lyons on Lynn’s Podcast, flusterclux

In this 36 minute audio interview with David Wilson from the podcast, On Another Track, Michael focuses on why skills work better than pills in managing depression.

In this 1 hour AAMFT Podcast, Dr. Karam’s interview with Michael highlights Michael’s work over the years including his impact on the fields of clinical hypnosis, depression, and strategic outcome focused psychotherapies.

In this interview Michael shares stories of the pioneers in the field that influenced him, and his own work in applying systemic thinking to hypnosis and strategic therapy. He dispels myths about hypnosis and discusses the nature of suggestion imbedded in all therapy, and how he merges it into the treatment of depression.

In this 1 and 1/2 hour podcast with Neil Sattin from the podcast, Relationship Alive, Michael addresses the impact depression has on relationships and how to mitigate it.

This brief 16 minute interview was conducted on the Australian ABC Radio Show Life Matters with Natasha Mitchell. Michael addresses how hypnosis can be utilized for developing skills to manage depression and the limitations of the chemical imbalance theory of the brain.

In this 30 minute presentation Michael addresses the topic of Depression is Contagious: How our relationships can serve as the cause of, or the solution to, overcoming depression.

Depression: Powerpoint Presentation slides (mhGAP) recommended

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What is depression?

Everyone feels sad or low sometimes, but these feelings usually pass. Depression (also called major depression, major depressive disorder, or clinical depression) is different. It can cause severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working.

Depression can affect anyone regardless of age, gender, race or ethnicity, income, culture, or education. Research suggests that genetic, biological, environmental, and psychological factors play a role in the disorder.

Women are diagnosed with depression more often than men, but men can also be depressed. Because men may be less likely to recognize, talk about, and seek help for their negative feelings, they are at greater risk of their depression symptoms being undiagnosed and undertreated. Studies also show higher rates of depression and an increased risk for the disorder among members of the LGBTQI+ community.

In addition, depression can co-occur with other mental disorders or chronic illnesses, such as diabetes, cancer, heart disease, and chronic pain. Depression can make these conditions worse and vice versa. Sometimes, medications taken for an illness cause side effects that contribute to depression symptoms as well.

What are the different types of depression?

There are two common types of depression.

• Major depression includes symptoms of depressed mood or loss of interest, most of the time for at least 2 weeks, that interfere with daily activities.
• Persistent depressive disorder (also called dysthymia or dysthymic disorder) consists of less severe depression symptoms that last much longer, usually for at least 2 years.

Other types of depression include the following.

• Seasonal affective disorder comes and goes with the seasons, with symptoms typically starting in the late fall and early winter and going away during the spring and summer.
• Depression with symptoms of psychosis is a severe form of depression in which a person experiences psychosis symptoms, such as delusions or hallucinations.
• Bipolar disorder involves depressive episodes, as well as manic episodes (or less severe hypomanic episodes) with unusually elevated mood, greater irritability, or increased activity level.

Additional types of depression can occur at specific points in a woman’s life. Pregnancy, the postpartum period, the menstrual cycle, and menopause are associated with physical and hormonal changes that can bring on a depressive episode in some people.

• Premenstrual dysphoric disorder is a more severe form of premenstrual syndrome, or PMS, that occurs in the weeks before menstruation.
• Perinatal depression occurs during pregnancy or after childbirth. It is more than the “baby blues” many new moms experience after giving birth.
• Perimenopausal depression affects some women during the transition to menopause. Women may experience feelings of intense irritability, anxiety, sadness, or loss of enjoyment.

What are the signs and symptoms of depression?

Common signs and symptoms of depression include:

• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness or pessimism
• Feelings of irritability, frustration‚ or restlessness
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in hobbies and activities
• Fatigue, lack of energy, or feeling slowed down
• Difficulty concentrating, remembering, or making decisions
• Difficulty sleeping, waking too early in the morning, or oversleeping
• Changes in appetite or unplanned weight changes
• Physical aches or pains, headaches, cramps, or digestive problems without a clear physical cause that do not go away with treatment
• Thoughts of death or suicide or suicide attempts

Depression can also involve other changes in mood or behavior that include:

• Increased anger or irritability
• Feeling restless or on edge
• Becoming withdrawn, negative, or detached
• Increased engagement in high-risk activities
• Greater impulsivity
• Increased use of alcohol or drugs
• Isolating from family and friends
• Inability to meet responsibilities or ignoring other important roles
• Problems with sexual desire and performance

Not everyone who is depressed shows all these symptoms. Some people experience only a few symptoms, while others experience many. Depression symptoms interfere with day-to-day functioning and cause significant distress for the person experiencing them.

If you show signs or symptoms of depression and they persist or do not go away, talk to a health care provider. If you see signs of depression in someone you know, encourage them to seek help from a mental health professional.

If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide and Crisis Lifeline   at 988 or chat at 988lifeline.org   . In life-threatening situations, call 911 .

How is depression diagnosed?

To be diagnosed with depression, a person must have symptoms most of the day, nearly every day, for at least 2 weeks. One of the symptoms must be a depressed mood or a loss of interest or pleasure in most activities. Children and adolescents may be irritable rather than sad.

Although several persistent symptoms, in addition to low mood, are required for a depression diagnosis, people with only a few symptoms may benefit from treatment. The severity and frequency of symptoms and how long they last vary depending on the person.

If you think you may have depression, talk to a health care provider, such as a primary care doctor, psychologist, or psychiatrist. During the visit, the provider may ask when your symptoms began, how long they have lasted, how often they occur, and if they keep you from going out or doing your usual activities. It may help to take some notes about your symptoms before the visit.

Certain medications and medical conditions, such as viruses or thyroid disorders, can cause the same symptoms as depression. A provider can rule out these possibilities by doing a physical exam, interview, and lab tests.

Does depression look the same in everyone?

Depression can affect people differently depending on their age.

• Children may be anxious or cranky, pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die.
• Older children and teens may get into trouble at school, sulk, be easily frustrated‚ feel restless, or have low self-esteem. They may have other disorders, such as anxiety, an eating disorder, attention-deficit/hyperactivity disorder, or substance use disorder. Older children and teens are also more likely to experience excessive sleepiness (called hypersomnia) and increased appetite (called hyperphagia).
• Young adults are more likely to be irritable, complain of weight gain and hypersomnia, and have a negative view of life and the future. They often have other disorders, such as generalized anxiety disorder, social phobia, panic disorder, or substance use disorder.
• Middle-aged adults may have more depressive episodes, decreased libido, middle-of-the-night insomnia, or early morning waking. They often report stomach problems, such as diarrhea or constipation.
• Older adults often feel sadness, grief, or other less obvious symptoms. They may report a lack of emotions rather than a depressed mood. Older adults are also more likely to have other medical conditions or pain that can cause or contribute to depression. Memory and thinking problems (called pseudodementia) may be prominent in severe cases.

Depression can also look different in men versus women, such as the symptoms they show and the behaviors they use to cope with them. For instance, men (as well as women) may show symptoms other than sadness, instead seeming angry or irritable.

For some people, symptoms manifest as physical problems (for example, a racing heart, tightened chest, chronic headaches, or digestive issues). Many men are more likely to see a health care provider about these physical symptoms than their emotional ones. While increased use of alcohol or drugs can be a sign of depression in any person, men are also more likely to use these substances as a coping strategy.

How is depression treated?

Depression treatment typically involves psychotherapy (in person or virtual), medication, or both. If these treatments do not reduce symptoms sufficiently, brain stimulation therapy may be another option.

Choosing the right treatment plan is based on a person’s needs, preferences, and medical situation and in consultation with a mental health professional or a health care provider. Finding the best treatment may take trial and error.

For milder forms of depression, psychotherapy is often tried first, with medication added later if the therapy alone does not produce a good response. People with moderate or severe depression usually are prescribed medication as part of the initial treatment plan.

Psychotherapy

Psychotherapy (also called talk therapy or counseling) can help people with depression by teaching them new ways of thinking and behaving and helping them change habits that contribute to depression. Psychotherapy occurs under the care of a licensed, trained mental health professional in one-on-one sessions or with others in a group setting.

Psychotherapy can be effective when delivered in person or virtually via telehealth. A provider may support or supplement therapy using digital or mobile technology, like apps or other tools.

Evidence-based therapies to treat depression include cognitive behavioral therapy and interpersonal therapy. Using other forms of psychotherapy, such as psychodynamic therapy, for a limited time also may help some people with depression.

• Cognitive behavioral therapy (CBT) : With CBT, people learn to challenge and change unhelpful thoughts and behaviors to improve their depressive and anxious feelings. Recent advances in CBT include adding mindfulness principles and specializing the therapy to target specific symptoms like insomnia.
• Interpersonal therapy (IPT) : IPT focuses on interpersonal and life events that impact mood and vice versa. IPT aims to help people improve their communication skills within relationships, form social support networks, and develop realistic expectations to better deal with crises or other issues that may be contributing to or worsening their depression.

Learn more about psychotherapy .

Antidepressants are medications commonly used to treat depression. They work by changing how the brain produces or uses certain chemicals involved in mood or stress.

Antidepressants take time—usually 4−8 weeks—to work, and problems with sleep, appetite, and concentration often improve before mood lifts. Giving a medication a chance to work is important before deciding whether it is right for you.

Treatment-resistant depression occurs when a person doesn’t get better after trying at least two antidepressants. Esketamine is a medication approved by the U.S. Food and Drug Administration (FDA) for treatment-resistant depression. Delivered as a nasal spray in a doctor’s office, clinic, or hospital, the medication acts rapidly, typically within a couple of hours, to relieve depression symptoms. People will usually continue to take an antidepressant pill to maintain the improvement in their symptoms.

Another option for treatment-resistant depression is to combine an antidepressant with a different type of medication that may make it more effective, such as an antipsychotic or anticonvulsant medication.

All medications can have side effects. Talk to a health care provider before starting or stopping any medication. Learn more about antidepressants .

Note : In some cases, children, teenagers, and young adults under 25 years may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. The FDA advises that patients of all ages taking antidepressants be watched closely, especially during the first few weeks of treatment.

Information about medication changes frequently. Learn more about specific medications like esketamine, including the latest approvals, side effects, warnings, and patient information, on the FDA website  .

Brain stimulation therapy

Brain stimulation therapy is an option when other depression treatments have not worked. The therapy involves activating or inhibiting the brain with electricity or magnetic waves.

Although brain stimulation therapy is less frequently used than psychotherapy and medication, it can play an important role in treating depression in people who have not responded to other treatments. The therapy generally is used only after a person has tried psychotherapy and medication, and those treatments usually continue. Brain stimulation therapy is sometimes used as an earlier treatment option when severe depression has become life-threatening, such as when a person has stopped eating or drinking or is at a high risk of suicide.

The FDA has approved several types of brain stimulation therapy. The most used are electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS). Other brain stimulation therapies are newer and, in some cases, still considered experimental. Learn more about brain stimulation therapies .

Natural products

The FDA has not approved any natural products for treating depression. Although research is ongoing and findings are inconsistent, some people report that natural products, including vitamin D and the herbal dietary supplement St. John’s wort, helped their depression symptoms. However, these products can come with risks, including, in some cases, interactions with prescription medications.

Do not use vitamin D, St. John’s wort, or other dietary supplements or natural products without first talking to a health care provider. Rigorous studies must test whether these and other natural products are safe and effective.

How can I take care of myself?

Most people with depression benefit from mental health treatment. Once you begin treatment, you should gradually start to feel better. Go easy on yourself during this time. Try to do things you used to enjoy. Even if you don’t feel like doing them, they can improve your mood.

Other things that may help:

• Try to get physical activity. Just 30 minutes a day of walking can boost your mood.
• Try to maintain a regular bedtime and wake-up time.
• Eat regular, healthy meals.
• Do what you can as you can. Decide what must get done and what can wait.
• Connect with people. Talk to people you trust about how you are feeling.
• Delay making important life decisions until you feel better. Discuss decisions with people who know you well.
• Avoid using alcohol, nicotine, or drugs, including medications not prescribed for you.

How can I find help for depression?

You can learn about ways to get help and find tips for talking with a health care provider on the NIMH website.

The Substance Abuse and Mental Health Services Administration (SAMHSA) also has an online tool to help you find mental health services  in your area.

How can I help a loved one who is depressed?

If someone you know is depressed, help them see a health care provider or mental health professional. You also can:

• Offer support, understanding, patience, and encouragement.
• Invite them out for walks, outings, and other activities.
• Help them stick to their treatment plan, such as setting reminders to take prescribed medications.
• Make sure they have transportation or access to therapy appointments.
• Remind them that, with time and treatment, their depression can lift.

What are clinical trials and why are they important?

Clinical trials are research studies that look at ways to prevent, detect, or treat diseases and conditions. These studies help show whether a treatment is safe and effective in people. Some people join clinical trials to help doctors and researchers learn more about a disease and improve health care. Other people, such as those with health conditions, join to try treatments that aren’t widely available.

NIMH supports clinical trials across the United States. Talk to a health care provider about clinical trials and whether one is right for you. Learn more about  participating in clinical trials .

For more information

Learn more about mental health disorders and topics . For information about various health topics, visit the National Library of Medicine’s MedlinePlus   .

The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health NIH Publication No. 24-MH-8079 Revised 2024

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Frequently Asked Questions about Depression

Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms must be present for at least two weeks.

Impactful Depression Research Discoveries by Foundation Grantees:

• Rapid-Acting Antidepressant Heralded as Biggest Breakthrough in Depression Research in 50 years
• Development of TMS for Treatment-Resistant Depression
• Interactive Parent-Child Therapy Reduced Depression Symptoms in Very Young Children
• Foundation Grantee Shows Treating Inflammation May Improve Resistant Depression

Recent Depression Research Discoveries by Foundation Grantees:

• Impact of Mother’s Depressive Symptoms Just Before and After Childbirth Upon Child’s Brain Development
• Study Links Brain Connectivity Patterns with Response to Specific Antidepressant and Placebo
• Over Two Decades, 90 BBRF Grants Helped Build a Scientific Foundation for the First Rapid-Acting Antidepressants
• After 60 Years, Study Finds Children of Mothers with Bacterial Infections During Pregnancy Have Elevated Psychosis Risk

For more lay-friendly, summarized Depression Research Discoveries,  click here .

Clinical depression is a serious condition that negatively affects how a person thinks, feels, and behaves. In contrast to normal sadness, clinical depression is persistent, often interferes with a person’s ability to experience or anticipate pleasure, and significantly interferes with functioning in daily life. Untreated, symptoms can last for weeks, months, or years; and if inadequately treated, depression can lead to significant impairment, other health-related issues, and in rare cases, suicide.

A person is diagnosed with a major depression when he or she experiences at least five of the symptoms listed below for two consecutive weeks. At least one of the five symptoms must be either (1) depressed mood or (2) loss of interest or pleasure. Symptoms include:

• Depressed mood most of the day, nearly every day
• Markedly diminished interest or pleasure in activities most of the day, nearly every day
• Changes in appetite that result in weight losses or gains unrelated to dieting
• Changes in sleeping patterns
• Loss of energy or increased fatigue
• Restlessness or irritability
• Feelings of anxiety
• Feelings of worthlessness, helplessness, or hopelessness
• Inappropriate guilt
• Difficulty thinking, concentrating, or making decisions
• Thoughts of death or attempts at suicide

The first step to being diagnosed is to visit a doctor for a medical evaluation. Certain medications, and some medical conditions such as thyroid disorder, can cause similar symptoms as depression. A doctor can rule out these possibilities by conducting a physical examination, interview and lab tests. If the doctor eliminates a medical condition as a cause, he or she can implement treatment or refer the patient to a mental health professional. Once diagnosed, a person with depression can be treated by various methods. The mainstays of treatment for depression are any of a number of antidepressant medications and psychotherapy, which can also be used in combination.

For severe, treatment-resistant depression, studies have been done showing Deep Brain Stimulation may be an option. Learn more in this webinar featuring Dr. Helen Mayberg :

Depression is twice as common among women as among men. About 20 percent of women will experience at least one episode of depression across their lifetime. Scientists are examining many potential causes for and contributing factors to women’s increased risk for depression. Biological, life cycle, hormonal and psychosocial factors unique to women may be linked to women’s higher depression rates. Researchers have shown, for example, that hormones affect brain chemistry, impacting emotions and mood. Before adolescence, girls and boys experience depression at about the same frequency. By adolescence, however, girls become more likely to experience depression than boys. Research points to several possible reasons for this imbalance. The biological and hormonal changes that occur during puberty likely contribute to the sharp increase in rates of depression among adolescent girls. In addition, research has suggested that girls are more likely than boys to continue feeling bad after experiencing difficult situations or events, suggesting they are more prone to depression.

Women are particularly vulnerable to depression after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. Many new mothers experience a brief episode of mild mood changes known as the “baby blues.” These symptoms usually dissipate by the 10th day. PPD lasts much longer than 10 days, and can go on for months following child birth. Acute PPD is a much more serious condition that requires active treatment and emotional support for the new mother. Some studies suggest that women who experience PPD often have had prior depressive episodes.

Menopause is defined as the state of an absence of menstrual periods for 12 months. Menopause is the point at which estrogen and progesterone production decreases permanently to very low levels. The ovaries stop producing eggs and a woman is no longer able to get pregnant naturally. During the transition into menopause, some women experience an increased risk for depression. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.

For older adults who experience depression for the first time later in life, other factors, such as changes in the brain or body, may be at play. For example, older adults may suffer from restricted blood flow, a condition called ischemia. Over time, blood vessels become less flexible. They may harden and prevent blood from flowing normally to the body’s organs, including the brain. If this occurs, an older adult with no family or personal history of depression may develop what some doctors call “vascular depression.” Those with vascular depression also may be at risk for a coexisting cardiovascular illness, such as heart disease or a stroke.

Researchers are looking for ways to better understand, diagnose and treat depression among all groups of people. Studying strategies to personalize care for depression, such as identifying characteristics of the person that predict which treatments are more likely to work, is an important goal.

The ability of ketamine to produce a rapid and efficacious antidepressant response by a completely novel mechanism is considered by many experts the most important finding in the depression field in 50 years. Originally developed as an anesthetic, ketamine is an antagonist of the NMDA receptor on a subset of brain cells. It often produces rapid (within hours) antidepressant actions in patients who have failed to respond to conventional antidepressants (i.e., are considered treatment-resistant). Ketamine is psychoactive and has potentially dangerous side effects; it has a past history of being abused as a street drug. Studies aimed at characterizing the mechanisms by which ketamine works rapidly and effectively in severely depressed individuals is likely to lead to novel targets and agents that are safer and more long-lasting, and could revolutionize the treatment of depression. Numerous BBRF  Grants support this work , including a number that are attempting to develop ketamine analogs – compounds that act like ketamine but lack its side-effects.

Treatment-resistant depression (TRD) is a term used in clinical psychiatry to describe cases of major depressive disorder that do not respond to standard treatments (at least two courses of antidepressant treatments). For many people, antidepressant treatment and/or ‘talk’ therapy (such as Cognitive Behavioral Therapy) ease symptoms of depression, but with treatment-resistant depression, little to no relief is realized. Treatment-resistant depression symptoms can range from mild to severe and may require trying a number of approaches to identify what helps. (Source: Biological Psychiatry)

Treatment of resistant depression has most commonly been treated with electroconvulsive therapy (ECT). ECT has been modified to avoid the pain previously associated with it and is the most effective and quick-acting treatment for resistant depression. The downside is that it works by inducing brain seizures and can impair memory. Its therapeutic benefits can also fade over time. New methods of brain stimulation also offer the possibility of relief. These technologies exploit the fact that the brain is an electrical organ: it responds to electrical and magnetic stimulation to modulate brain circuits and change brain activity. Repetitive transcranial magnetic stimulation (rTMS), pioneered by Dr. Mark George with the support of NARSAD grants, was approved by the FDA in 2008 as a treatment for some otherwise untreatable depressions. rTMS is a noninvasive method that works through a coil held over the target area of the brain. A magnetic field passes through the skull to activate the appropriate brain circuit and no seizures are induced. Deep brain stimulation (DBS), a technique adapted for treating depression by Dr. Helen Mayberg with the support of NARSAD grants, works through electrodes planted deep in the brain. Another method, vagus nerve stimulation (VNS), stimulates the vagus nerve in the neck to therapeutically activate brain function. Magnetic seizure therapy (MST) combines rTMS and ECT to achieve a safer form of seizure therapy. MST has been supported through NARSAD Grants to Dr. Sarah Lisanby. Recently, Foundation grantees at the University of Pittsburgh have successfully experimented on a small number of patients with treatment-resistant depression, discovering underlying metabolic deficiencies and successfully treating these. In one subset of patients, a deficiency in cerebral folate was addressed by administering folinic acid. Patients’ depression symptoms declined significantly when these metabolic problems were treated. For some individuals, depression reached remission.

Learn more about TMS for depression in this webinar featuring Dr. Sarah Lisanby :

The first attempts at defining depression as a biologically-based illness hinged on a theory of a ‘chemical imbalance’ in the brain. It was thought that too much or too little of essential signal-transmitting chemicals—neurotransmitters—were present in the brain. This idea has been useful—that the brain is a kind of chemical soup in which there may be too much dopamine or too little serotonin, but it is now begin replaced by much more sophisticated knowledge about how the brain works, made possible by basic research. All the current antidepressants were developed during the period when the chemical-soup theory was in vogue. But now, many researchers are looking to understand in greater detail the brain biology that underlies depression’s symptoms so that novel therapies can be found.

Throughout this website you will find ideas for new depression treatments in greater detail. Efforts to create new classes of antidepressants, based on novel targets have borne fruit. A docking port on brain cells called the mu opioid receptor is the focus of one such effort. Other efforts focus not on the serotonin pathway, as do current “SSRI” drugs such as Prozac, but another pathway, that of another key neurotransmitter, called glutamate. A previously obscure brain area called the lateral habenula may be involved in depression pathology in some instances, due to glutamate hyperactivity. A drug able to specifically lower the activity in that region is a plausible drug discovery objective. Other researchers have been working on the idea that drugs that can mimic the biochemical and biological factors rendering certain people resilient to factors such as severe or chronic stress may have a future in depression treatment. A drug is now being tested that in preliminary trials has helped to reduce postpartum depression. Other researchers have been studying the ability to help women resist depression in the perinatal period through hormone treatments, or, in other work, via treatments that target the maternal immune system, which may be implicated in a subset of postpartum depression. Research has begun to see if administering certain strains of bacteria in depressed individuals might give a boost to their immune system and help reduce depression symptoms. Trying to alleviate depression via changes in diet – e.g., a Mediterranean diet, in one recent study – or omega-3 (“fish oil”) supplements is the subject of other Foundation-supported research. Yet another path that may lead to better outcomes in the future is bright-light therapy, which was first used to help people with seasonal affective disorder. It may have wider applications. It is also important to note research by grantees that has suggested the ability of even a short course of talk therapy to help alleviate depression in mothers with major depression, while at the same time helping their children. Such therapy worked best when it focused on the mother’s relationship with her child, the research revealed.

Dr. J. John Mann presented a webinar titled: Brain Plasticity: The Effects of Antidepressants on Major Depression in which he discusses why we need to better understand how antidepressants including SSRIs, lithium, and ketamine exert their therapeutic effects, so we can find newer more effective and rapidly acting treatments for depression:

Brain imaging has confirmed the biological nature of many psychiatric illnesses over the past twenty years. Yvette Sheline, M.D., in the mid-1990s, used functional magnetic resonance imaging (fMRI) to identify structural brain changes in depressed patients and established depression as a brain disease.

Using positron emission tomography (PET) scan images, Dr. Helen Mayberg of the Icahn School of Medicine at Mount Sinai, identified, in 2013, specific brain activity that can potentially predict whether people with major depressive disorder will best respond to an antidepressant medication or psychotherapy. This important new work offers a first potential imaging biomarker for treatment selection. A team of researchers including NARSAD Grantee Stefan G. Hoffman, Ph.D., of Boston University and Frida E. Polli, Ph.D., of Massachusetts Institute of Technology have used brain imaging to predict the success of cognitive behavioral therapy, a specific type of talk therapy often used to help treat a wide range of mental illnesses including anxiety disorders, depression, and schizophrenia.  Research by Dr. Conor Liston of Weill Cornell Medical School, and colleagues, has used brain scans to identify four distinct “biotypes” of depression. Strikingly, patients in one of these four categories were about three times more likely to respond to a noninvasive treatment known as transcranial magnetic stimulation (TMS) than patients in two of the other categories. This is a good example of the power that biomarkers can have in the years just ahead to help direct people with depression to treatments most likely to help them.  

Variations in genes – different kinds of DNA mutations, both common and rare – have been solidly linked to a number of serious psychiatric disorders including schizophrenia, bipolar disorder and autism. It is reasonable to wonder why similar progress has not been made yet in the study of the genetic factors contributing to depression. Researchers have made many attempts to search for such factors, but have not come up with results that statisticians consider “statistically meaningful.” One way of explaining the issue in studying depression concerns that very large number of people whom it affects. The power of massive genomic studies of patients (who are compared with unaffected individuals) evaporates if the people being compared have similar illnesses that have very different underlying genetic profiles. People with major depression might be grouped according to sex; whether or not they have recurrent depression; age at onset; symptom patterns; whether or not they were abused or under chronic stress early in life, for example. There is very good reason for progress on the genetic front, however. Foundation grantee Patrick Sullivan, M.D. and others have had success in finding the first reliable signals of commonly seen genetic variations in people with schizophrenia. To do so, they need to assemble a patient sample, across continents, numbering in the tens of thousands. They founded the Psychiatric Genomic Consortium to accomplish this. PGC scientists estimate that the inflection point in depression studies may be 75,000 to 100,000 study participants, a goal the PGC is working toward. It’s not that there is no genetic signal in depression, in other words. It’s a question of assembling a well-documented sample of patients of sufficient size to “tease out” the embedded genetic “signals,” which will point toward risk genes for the illness.

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2022 International Mental Health Research Symposium

OCD: Using Genome Data to Predict Risk, Symptoms and Treatment Response

Developing New Treatments for Mania Using Brain-Based Risk Markers

Self-Control Gone Awry: The Cognitive Neuroscience Behind Bulimia Nervosa

Cognitive Impairment in Psychosis: What it is and How it's Treated

Advice on Diagnosing and Treating Bipolar Disorder

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Using Rapid-Acting Brain Stimulation for Treatment-Resistant Depression

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4.1: Clinical Presentation – Depressive Disorders

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• Page ID 161365

• Alexis Bridley and Lee W. Daffin Jr.
• Washington State University

Learning Objectives

• Distinguish the two distinct groups of mood disorders.
• Identify and describe the two types of depressive disorders.
• Classify symptoms of depression.
• Describe premenstrual dysphoric disorder.

Distinguishing Mood Disorders

Within mood disorders are two distinct groups—individuals with depressive disorders and individuals with bipolar disorders. The key difference between the two mood disorder groups is episodes of mania/hypomania. More specifically, in bipolar I disorder, the individual experiences a manic episode that “may have been preceded by and may be followed by hypomanic or major depressive episodes” (APA, 2022, pg. 139) whereas for bipolar II disorder, the individual has experienced in the past or is currently experiencing a hypomanic episode and has experienced in the past or is currently experiencing a major depressive episode. In contrast, individuals presenting with a depressive disorder have never experienced a manic or hypomanic episode.

Types of Depressive Disorders

The two most common types of depressive disorders are major depressive disorder (MDD) and persistent depressive disorder (PDD). Persistent depressive disorder , which in the DSM-5 now includes the diagnostic categories of dysthymia and chronic major depression, is a continuous and chronic form of depression. While the symptoms of PDD are very similar to MDD, they are usually less acute, as symptoms tend to ebb and flow over a long period (i.e., more than two years). Major depressive disorder , on the other hand, has discrete episodes lasting at least two weeks in which there are substantial changes in affect, cognition, and neurovegetative functions (APA, 2022, pg. 177).

It should be noted that after a careful review of the literature, premenstrual dysphoric disorder , was moved from “Criteria Sets and Axes Provided for Future Study” in the DSM-IV to Section II of DSM-5 as the disorder was confirmed as a “specific and treatment-responsive form of depressive disorder that begins sometime following ovulation and remits within a few days of menses and has a marked impact on functioning” (APA, 2022, pg. 177).

The DSM-5 also added a new diagnosis, disruptive mood dysregulation disorder (DMDD), for children up to 12 years of age, to deal with the potential for overdiagnosis and treatment of bipolar disorder in children, both in the United States and internationally. Children with DMDD present with persistent irritability and frequent episodes of extreme behavioral dyscontrol and so develop unipolar, not bipolar, depressive disorders or anxiety disorders as they move into adolescence and adulthood.

For a discussion of DMDD, please visit our sister book, Behavioral Disorders of Childhood:

https://opentext.wsu.edu/behavioral-disorders-childhood/

Symptoms Associated with Depressive Disorders

When making a diagnosis of depression, there are a wide range of symptoms that may be present. These symptoms can generally be grouped into four categories: mood, behavioral, cognitive, and physical symptoms.

4.1.3.1. Mood. While clinical depression can vary in its presentation among individuals, most, if not all individuals with depression will report significant mood disturbances such as a depressed mood for most of the day and/or feelings of anhedonia , which is the loss of interest in previously interesting activities.

4.1.3.2. Behavioral. Behavioral issues such as decreased physical activity and reduced productivity—both at home and work—are often observed in individuals with depression. This is typically where a disruption in daily functioning occurs as individuals with depressive disorders are unable to maintain their social interactions and employment responsibilities.

4.1.3.3. Cognitive. It should not come as a surprise that there is a serious disruption in cognitions as individuals with depressive disorders typically hold a negative view of themselves and the world around them. They are quick to blame themselves when things go wrong, and rarely take credit when they experience positive achievements. Individuals with depressive disorders often feel worthless, which creates a negative feedback loop by reinforcing their overall depressed mood. They also report difficulty concentrating on tasks, as they are easily distracted from outside stimuli. This assertion is supported by research that has found individuals with depression perform worse than those without depression on tasks of memory, attention, and reasoning (Chen et al., 2013). Finally, thoughts of suicide and self-harm do occasionally occur in those with depressive disorders ( Note – this will be discussed in more detail in Section 4.3 ).

4.1.3.4. Physical. Changes in sleep patterns are common in those experiencing depression with reports of both hypersomnia and insomnia. Hypersomnia , or excessive sleeping, often impacts an individual’s daily functioning as they spend the majority of their time sleeping as opposed to participating in daily activities (i.e., meeting up with friends or getting to work on time). Reports of insomnia are also frequent and can occur at various points throughout the night to include difficulty falling asleep, staying asleep, or waking too early with the inability to fall back asleep before having to wake for the day. Although it is unclear whether symptoms of fatigue or loss of energy are related to insomnia issues, the fact that those experiencing hypersomnia also report symptoms of fatigue suggests that these symptoms are a component of the disorder rather than a secondary symptom of sleep disturbance.

Additional physical symptoms, such as a change in weight or eating behaviors, are also observed. Some individuals who are experiencing depression report a lack of appetite, often forcing themselves to eat something during the day. On the contrary, others overeat, often seeking “comfort foods,” such as those high in carbohydrates. Due to these changes in eating behaviors, there may be associated changes in weight.

Finally, psychomotor agitation or retardation, which is the purposeless or slowed physical movement of the body (i.e., pacing around a room, tapping toes, restlessness, etc.) is also reported in individuals with depressive disorders.

Diagnostic Criteria and Features for Depressive Disorders

4.1.4.1. Major depressive disorder (MDD). According to the DSM-5-TR (APA, 2022), to meet the criteria for a diagnosis of major depressive disorder, an individual must experience at least five symptoms across the four categories discussed above, and at least one of the symptoms is either 1) a depressed mood most of the day, almost every day, or 2) loss of interest or pleasure in all, or most, activities, most of the day, almost every day. These symptoms must be present for at least two weeks and cause clinically significant distress or impairment in important areas of functioning such as social and occupational. The DSM-5 cautions that responses to a significant loss (such as the death of a loved one, financial ruin, and discovery of a serious medical illness or disability), can lead to many of the symptoms described above (i.e., intense sadness, rumination about the loss, insomnia, etc.) but this may be the normal response to such a loss. Though the individual’s response resembles a major depressive episode, clinical judgment should be utilized in making any diagnosis and be based on the clinician’s understanding of the individual’s personal history and cultural norms related to how members should express distress in the context of loss.

4.1.4.2. Persistent depressive disorder (PDD). For a diagnosis of persistent depressive disorder, an individual must experience a depressed mood for most of the day, for more days than not, for at least two years. (APA, 2022) . This feeling of a depressed mood is also accompanied by two or more additional symptoms, to include changes in appetite, insomnia or hypersomnia, low energy or fatigue, low self-esteem, feelings of hopelessness, and poor concentration or difficulty with decision making. The symptoms taken together cause clinically significant distress or impairment in important areas of functioning such as social and occupational and these impacts can be as great as or greater than MDD. The individual may experience a temporary relief of symptoms; however, the individual will not be without symptoms for more than two months during this two-year period.

Making Sense of the Disorders

In relation to depressive disorders, note the following:

• Diagnosis MDD …… if symptoms have been experienced for at least two weeks and can be regarded as severe
• Diagnosis PDD … if the symptoms have been experienced for at least two years and are not severe

4.1.4.3. Premenstrual dysphoric disorder. In terms of premenstrual dysphoric disorder, the DSM-5-TR states in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, being improving with a few days after menses begins, and disappear or become negligible in the week postmenses. Individuals diagnosed with premenstrual dysphoric disorder must have one or more of the following: increased mood swings, irritability or anger, depressed mood, or anxiety/tension. Additionally, they must have one or more of the following to reach a total of five symptoms: anhedonia, difficulty concentrating, lethargy, changes in appetite, hypersomnia or insomnia, feelings of being overwhelmed or out of control, and/or experience breast tenderness or swelling. The symptoms lead to issues at work or school (i.e., decreased productivity and efficiency), within relationships (i.e., discord in the intimate partner relationship or with children, friends, or other family members), and with usual social activities (i.e., avoidance of the activities).

Key Takeaways

You should have learned the following in this section:

• Mood disorder fall into one of two groups – depressive or bipolar disorders – with the key distinction between the two being episodes of mania/hypomania.
• Symptoms of depression fall into one of four categories – mood, behavioral, cognitive, and physical.
• Persistent Depressive Disorder shares symptoms with Major Depressive Disorder though they are usually not as severe and ebb and flow over a period of at least two years.
• Premenstrual dysphoric disorder presents as mood lability, irritability, dysphoria, and anxiety symptoms occurring often during the premenstrual phase of the cycle and remit around the beginning of menses or shortly thereafter.

Review Questions

• What are the different categories of mood disorder symptoms? Identify the symptoms within each category.
• What are the key differences in a major depression and a persistent depressive disorder diagnosis?
• What is premenstrual dysphoric disorder?

3 Signs of Hidden Depression

Despite the emotional tempest, signs of depression may be subtle..

Updated April 10, 2024 | Reviewed by Ray Parker

• What Is Depression?
• Find counselling to overcome depression
• Depression isn't always obvious.
• Noticing hidden signs can expedite evaluation and intervention.
• Sighing, frustration, and agitation can be revealing of underlying depression.

Depression is a ubiquitous term, and it seems most people have some idea, if not entirely accurate, of what it means. The symptom of sadness might come to mind for some, while others envision a suicidal gothic character. What lies between these extreme ends of the continuum—an isolated, fleeting symptom and an almost caricature representation—is vast. There are subtypes of depression, and even people suffering from the same subtype can present differently.

Further, some people are more internalized or externalized in their expression and possess greater or lesser abilities in managing. Jane, for instance, upon evaluation, might possess eight symptoms but seems OK because she works and cares for her family. Joe, on the other hand, might have five and be unable to care for himself. The severity of depression isn't necessarily weighed by several symptoms but by how impaired someone is by them. Regardless, given Joe’s symptoms are more visual, he might get help and live a higher quality of life while Jane silently suffers through life, or, worse, to a tragic ending.

With this in mind, it is important to pay attention to hidden signs of depression. There might be more to someone always sighing, frustrated, and agitated than meets the eye.

Unusual and Subtle Signs

Would it surprise you that depression can be hidden in plain sight, perhaps chameleonized as a "different issue?"

People arriving for sleep problems, anger , or infidelity may just be presenting the tip of the depression iceberg. As I wrote about in this earlier post, for instance, aggressive or thrill-seeking behaviors can be downstream effects of an internalized process. This is especially true for males/cultures where displaying emotional “weakness” is considered dishonorable.

Internalized emotional pressure, coupled with insomnia and poor diet , might escape as anger reactions. Cheating or indiscriminate sex may assuage one’s low self-image , providing a sense of desirability or thrill in the face of an otherwise flat internal landscape. Providers should always provide careful diagnostic assessments, as no symptom/behavior exists in a vacuum. Trying to address the anger or infidelity alone will only provide tenuous abatement at best, like clipping back a weed but leaving the root to grow it back.

More Complicated Dynamics

Anyone who has worked with angry people knows that “They’re just an angry person” isn’t likely. This is also the case with someone who sighs a lot, acts frustrated, and appears rattled. There’s an internal conflict being expressed, and often, a mood or personality complication behind it.

Behaviors are expressions of thoughts and feelings.

People who are depressed often present with sighing, frustration/irritability, and agitation, but if the package presents itself sans obvious depression, don’t write it off. Depression could be driving that demeanor, but the person is otherwise managing to conceal the foundational struggle. Take the case of Jessie (composite identity), who was referred by his employer to the employee assistance program for appearing increasingly discontent over recent months.

Jessie was never the life of the office, but he was dependable and pleasant enough. Insidiously, he had taken to exaggerated exhaling throughout the day, as if trying to externalize some burden so his day could go on. His work quality and productivity were not suffering, but he uncharacteristically became frustrated if there was a meeting or he was approached by colleagues, which disrupted his work. In meetings, it was hard not to notice his being fidgety or that he might roll his eyes and look about in an “I can’t believe this” gesture like his time was being wasted.

Jessie’s workload hadn’t changed, and there was no inter-collegiate problem present. However, his supervisor, Jenna, was concerned that his demeanor, despite his ongoing productivity, was placing a burden on the office milieu and referred him to the employee assistance program.

The Sigh-Depression Connection

Sighing alone isn’t necessarily a signal of negative emotionality ( Danvers et al ., 2021). We sigh every few minutes, as it is normal for respiratory function to inflate alveoli in the lungs (Li et al., 2016). However, when pronounced sighs are presented regularly with other observations, as Jenna noticed, maybe it’s time to check in with the person or oneself.

This is because we sigh more when stressed or emotional. Vlemincx et al. (2022) noted that “[Sighs reset] emotional states by facilitating emotional transitions.” Perhaps more frequent sighing helps people mired in negative emotions constantly reset to a manageable emotional state.

Agitation, of course, is not only a physical expression of one’s restless mental state but can serve as stimulation/preoccupation/distraction. It can also be an expression of frustration, which is not unusual in depressed people. This, of course, lends itself to sighing, too.

The inherent poor sleep and appetite of depression alone can cause irritation/agitation, but couple that with cognitive slowing and rumination of depression, and someone’s emotional experience could be akin to a pot with a lid on it beginning to boil; we don’t see the roil, but the shaking indicates something is up inside.

We all periodically roll our eyes, grunt, and/or hold our foreheads when frustrated, but when that fleeting state(s) becomes a trait, chronic internal turmoil likely keeps it afloat.

Clinical Implications

When encountering someone like Jessie, exploring their internal landscape is required for effective therapy :

After exchanging pleasantries, I said, “So, Jessie, we briefly spoke on the phone that you were referred because of seeming frustrated and on edge at work lately. What can you tell me about that?” Jessie went on to describe what Jenna did in the EAP referral.

“Seems like it’s become more noticeable over time," I replied. "I’m curious about what you can tell me about your experience as it was all building. Like, what changed? What has been on your mind in conjunction with all this?”

Though not directly answering the thought process question, Jessie reflected that for several months, he had been feeling “a grey mood” and could get irritable. He also slept more. It wasn’t the first time it happened. He remembered a similar event when his parents divorced when he was in his teens, 15 years earlier. Now, his mother had just divorced again and began “guilting” Jessie into doing things for her around the house. He set hard boundaries , engendering never-ending squabbling between him, his mother, and his siblings.

Jessie thought he kept any signs of bad moods hidden. Work was the most stimulating thing in his life at the moment, and he figured being occupied wouldn’t allow his bad mood to show through to colleagues. Work was an escape, but some of his inner world was escaping at work. Thankfully, it brought him to therapy, where he was able to work through his familial problems and not be left to stew in his emotions privately.

Robbins (2011) provides a good reminder of why it is important to keep vigilant for people like Jessie:

Because depression most immediately affects people’s inner mood and cognitive landscape, it is often “invisible” to outsiders. Thus, depression’s privacy can impede its early detection and thereby adequate treatment. These issues are compounded when the social stigma surrounding depression leads to patients intentionally hiding symptoms. Therefore, identifying observable, behavioral markers of depression is an important scientific endeavor with theoretical and clinical implications.

Danvers, A.F., Milek, A., Tackman, A.M., Kaplan, D.M., Robbins, M.L., Poslinelli, A., Moseley, S., Raison, C.L., Sbarra, D., & Mehl, M.R. (2021). Is frequent sighing an indicator of dispositional negative emotionality? A multi-sample, multi-measure naturalistic-observation study. Journal of Research in Personality , 90 , https://doi.org/10.1016/j.jrp.2020.104046

Li, P., Janczewski, W., Yackle, K., Kam, K., Pagliardini, S., Krasnow, M.A., & Feldman, J.A. (2016). The peptidergic control circuit for sighing. Nature, 530, 293–297 .

Robbins, M.L., Mehl, M.R., Holleran, S.E., & Kasle, S. (2011). Naturalistically observed sighing and depression in rheumatoid arthritis patients: a preliminary study. Health Psychology, 30 (1), 129-33. doi: 10.1037/a0021558. PMID: 21299301; PMCID: PMC3059549

Vlemincx, E., Severs, L., & Ramirez, J.M. (2022). The psychophysiology of the sigh: II: The sigh from the psychological perspective. Biological Psychology, 173 , https://doi.org/10.1016/j.biopsycho.2022.108386

Anthony Smith, LMHC, has 23 years of experience that includes the roles of therapist, juvenile court evaluator, professor, and counseling supervisor.

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