Major Depressive Disorder

Author: Elizabeth Milburn, CRNP

What is Major Depression and Major Depressive Disorder (MDD)?

Elizabeth Milburn, CRNP serving all of PA and NJ w/ in-office & virtual appointments.

Many people describe feeling depressed when they lose a loved one, when a relationship ends, when they get a bad grade, when plans fall through, when things are generally not going well, and so on. However, in the medical field depression means something very specific that is more significantly impactful than sad or low mood due to a tough situation.

To have a diagnosable case of depression (also called major depressive disorder or clinical depression), a person must be experiencing certain symptoms most of the day nearly every day for two or more weeks. One of these symptoms MUST be either a) depressed mood (also described as low, sad, blue, empty, hopeless, numb) OR b) a significantly diminished interest in nearly all usual activities.

There must also be five additional symptoms occurring most of the time during that same two weeks. These can include: a) significant weight change or appetite change, b) sleeping too much or difficulty sleeping, c) being visibly more restless or slow than usual, d) fatigue or loss of energy, e) feelings of worthlessness or excessive/inappropriate guilt, f) diminished ability to concentrate or make decisions, g) recurrent thoughts of death, feeling better off dead, thoughts about ending one’s life, or plans to end one’s life.

There must also be distress or negative effects on the person’s ability to function in areas of their life (like at work, home, school, others).

Depression and depressive episodes happen once, or can recur. Some individuals experience very frequent episodes, and some experience one or two over a lifetime. Some individuals experience these symptoms chronically for months or years in a row with little relief.

Who Gets Major Depression?

Anyone at any age can develop a major depressive episode. It is thought, as with most mental illnesses, that a combination of internal factors and external factors together cause depression. During a 12-month period 7% of the U.S. population will experience major depressive disorder. Females are 1.5 to 3 times more likely to experience depression than males starting in early adolescence. Individuals between 18 and 29 are three times more likely to experience depression than individuals 60 years and above. A child of a parent with major depression is 2 to 4 times more likely to develop the illness than the general population. (Data in this section obtained from, and According to, the Diagnostic and Statistical Manual of Mental Disorders 5).

Why Treat Major Depression?

There are many reasons to treat depression. The National Institute of Mental Health states that people with depression have a higher risk of developing diseases such as heart disease, diabetes, stroke, pain, osteoporosis, and Alzheimer’s disease.

Research has also shown that the more depressive episodes a person has, the more likely they are to have another. Someone who has had one episode is estimated to have a 50% chance of having another (Kupfer, 1991). Someone who has had two episodes is thought to be 80 to 90% likely to have a third episode (Kupfer, 1991).

Major depressive disorder, ultimately, can result in suicide attempts or completion. Suicide is permanent, and depressive episodes are typically not. Depressive episodes cloud thinking, judgment, and ability to problem solve or make decisions. Therefore, many suicide attempts are not the true intentions of the persons making them. Some lucky survivors of suicide attempts discuss immediate regret after taking action to end their life (Kevin Hines speaks about this publicly. His videos can be found on YouTube). According to the American Association of Suicidology: “the lifetime risk of suicide among patients with untreated depressive disorder is nearly 20% (Gotlib & Hammen, 2002). The suicide risk among treated patients is 141/100,000 (Isacsson et al, 2000).”

Finally, depression is a treatable medical condition. A lot of patients think they should be able to control depression on their own or think “everyone gets depressed.” For many folks with moderate to severe episodes, it’s about as controllable as a congenital heart defect, a pancreas that cannot make insulin, a broken leg, or an infection. Sure, there are things you can do that will help (i.e. exercise, yoga, journaling, good sleep schedule, seeing friends and family, keeping busy, controlling social media use, abstinence from substance use) but for many it cannot be willed away or completely controlled. At times medication is entirely necessary to achieve remission from symptoms, and the risks of taking medications are far less than the risks of untreated major depression.

How is Major Depression Treated?

For moderate to severe depression episodes, a combination of therapy and medication should be used. This combination typically yields the best results. However, due to preferences, time constraints, financial constraints, or other factors, some patients choose one or the other. One of these treatments is certainly better than no treatment at all. Mild depression can sometimes be improved with therapy and lifestyle changes.

There are many medications that can be used for major depressive disorder. The right medication(s) for an individual is/are chosen after careful evaluation which includes consideration of past medication trials, medical condition(s), co-occurring substance use, symptoms present, side effect risks, and preferences of the patient. The most common types medications used include: SSRIs, SNRIs, SGAs, NDRIs, and “other” antidepressants whose mechanisms do not fit into these categories. Less commonly used are TCAs and MAOIs. Medication effects and benefits should be monitored at regular intervals.

Medication abbreviation definitions and examples (list not exhaustive)

• SSRI– selective serotonin reuptake inhibitor (fluoxetine, paroxetine, citalopram, escitalopram, sertraline)
• SNRI– serotonin/norepinephrine reuptake inhibitor (duloxetine, venlafaxine, desvenlafaxine)
• SGA– second generation antipsychotic (aripiprazole, brexpiprazole, cariprazine, quetiapine)
• NDRI– norepinephrine/dopamine reuptake inhibitor (bupropion)
• Others– mirtazapine, trazodone, dextromethorophan+bupropion, ketamine, esketamine, vortioxetine, vilazodone
• TCAs– tricyclic antidepressants (nortriptyline, amitriptyline, doxepin, imipramine)
• MAOIs– monoamine oxidase inhibitors (phenelzine, selegiline patch, tranylcypromine, isocarboxazid)