(This blog will discuss the etiology, diagnostic criteria, and treatment of Major Depressive Disorder. While this is one of the most common causes of depression, there are many other conditions that can cause depression. Other conditions with depressive components (such as bipolar disorder, hypothyroidism, or schizoaffective disorder) will not be discussed. Links to the resources used while researching this blog, if not already explicitly referenced in the text, can be found at the bottom of this article.)

In all likelihood, you or someone you know is suffering from depression. Major Depressive Disorder (MDD) is one of the most common causes of depression in the United States, affecting millions. In 2017, 7.1% of U.S. adults were living with a diagnosis of MDD, with 13.1% of adults aged 18-25 having a diagnosis of MDD according to the National Institute of Mental Health. Despite progressive changes in public perception, mental health disorders are still stigmatized by many Americans. The advent of the internet has given many people access to information about the causes and treatments available for depression. While this has allowed opportunities for members of the public to educate themselves about options for the management of their depression, it has also created a platform which allows misinformation to be more easily spread. Corporations will claim that their “natural supplements” can treat depression, with no research to support their claims. Fear campaigns against depression medications will make outrageous accusations that psychiatric patients are being tranquilized with medications that are as addictive as heroin. While some drugs have the potential for abuse, many of these claims are unquestionably false and are intentionally attempting to mislead Americans with limited medical education. But have no fear! Arming yourself with a more complete understanding of the nature of depression and its treatments will allow you to see through these snake-oil salesmen with ease. To that end, let’s untangle the tangled web of misinformation surrounding depression.

Words like “sadness”, “grief”, and “depression” are all frequently used in our daily conversation, often interchangeably. However, these words take on a very different meaning when discussing mood disorders like Major Depressive Disorder (MDD). We feel sad when we receive bad news or when we fail to achieve some goal that we set for ourselves. Sadness is a normal emotion and part of everyday life. Grief after a significant personal loss is another normal process. Grief involves feelings of sadness that wax and wane over several months, before finally resolving. That is not to say that sadness and grief are not difficult obstacles to overcome, but it is important to distinguish them from true depression for the purpose of this discussion. Persistent, unrelenting feelings of sadness that impair a person’s quality of life are more akin to MDD. For a person to be diagnosed with MDD, they must meet specific criteria outlined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 is the product of over a decade of research by hundreds of international experts in the field of mental health. The DSM-5 is the most up-to-date manual for diagnosing and discussing mental illnesses. Under the DSM-5, a person must have five or more of the symptoms listed below during the same 2‐week time period that causes them to experience impaired functioning in their daily life. Additionally, at least one symptom must be either a depressed mood or loss of interest.

• 1. Depressed mood most of the day, nearly every day, as indicated in the subjective report or in observation made by others
• 2. Markedly diminished interest in pleasure in all, or almost all, activities most of the day and nearly every day
• 3. Significant weight loss when not dieting or weight gain, for example, more than 5 percent of body weight in a month or changes in appetite nearly every day
• 4. Insomnia or hypersomnia (sleeping too much) nearly every day
• 5. Psychomotor agitation or retardation nearly every day
• 6. Fatigue or loss of energy nearly every day
• 7. Feelings of worthlessness or excessive or inappropriate guilt
• 8. Diminished ability to think or concentrate, or indecisiveness nearly every day
• 9. Recurrent thoughts of death

Without meeting these requirements, a person cannot reliably be diagnosed with MDD and may not be a good candidate for the management of depression. If the symptoms on this list sound eerily similar to feelings that you experience on a daily basis, consider discussing them with your primary-care or family physician. Feelings of significant distress from these symptoms are often managed by family doctors, but may be referred to a psychiatrist for more in-depth management options.

Multiple factors can influence the development of depression. Major life trauma can be a trigger for depression in many people; others will develop depression without any inciting event, but may have a many family members with unexplained depression, similar to their own. The casual observer may try to argue that genetics or social stresses are to blame for someone’s depression. The reality is usually a bit more complicated. Framing mental illness in the context of “nature vs nurture” will ultimately miss the real issue. It is the interaction between a person’s physical predispositions and the circumstances of their life that determines their ultimate health outcomes. An analogy to a concert pianist is sometimes used to describe this trend. When a concert pianist performs to a sold-out crowd, does the music come from the pianist or the piano? The answer becomes much more clear when framed in this way. Neither the musician or the instrument can perform the task in isolation; the interaction between the two components generates the final product. Another analogy is that “genetics loads the gun, but life pulls the trigger”. Different people may react differently to the exact same stressor, simply based on their physiology. Robust studies on the inheritance of major depressive disorder estimate it to have a heritability of roughly 40%, but acknowledge that environmental factors play a significant role in the development of depression in an individual [1].

For many years, the mainstays of treatment for depression have been psychotherapy and antidepressant medications. Both treatment modalities have similar rates of success and patients should take an active part in the decision-making process with their doctor about which type of treatment they would like to pursue. Current recommendations from the American Psychological Association state that no specific type of psychotherapy is superior to any other, but recommend second-generation antidepressants for initial pharmacologic treatment of depression [2]. The term “second-generation antidepressants” refers to a loose collection of drugs, most of which work by boosting levels of serotonin, a chemical made naturally in the body. Initial studies have suggested that patients who have finished therapy for depression are less likely to relapse than patients who have finished a treatment plan with only antidepressant medications [3]. A combination of therapy and medications is also a perfectly reasonable option for depression that does not respond to therapy or medication alone. More severe depression may require additional treatment. Of note, the most effective and oldest method of treating depression has been electroconvulsive therapy (ECT). For over 80 years, ECT has been one of the most effective ways of managing depression. Although it is often stigmatized, ECT is safer than even a basic surgery, such as a gallbladder removal, and its most significant side-effect is temporary memory loss, which is not seen in all patients [4].

For all cases of depression, it is important for the patient to form a treatment plan that they think they can maintain. Most antidepressants will take 4-6 weeks before they begin to decrease symptoms of depression. Therapy is also unlikely to be successful if appointments are not consistently kept. Consistency of treatment is key for effective management of depression. All patients have the right to dictate what types of treatment they wish to pursue because they, ultimately, will be the ones responsible for maintaining the treatment regimens. People should feel empowered by their decision to pursue help for their depression. While they should remain open-minded to treatment that they may not have initially considered, people suffering from depression should feel confidently about which types of treatment they would like to pursue. A good doctor will try to educate their patients about the pros and cons of various treatment options. It is then up to the patient to decide which course of action they would like to pursue.

This is where the nebulous world of “alternative” treatments begins to come into consideration. Although the American Psychological Association has reported some success with exercise and use of St. John’s Wort (an herbal supplement), it is strongly recommended to consult with a physician before trying other over-the-counter supplements to treat depression. Most supplements are not formally endorsed by a major medical associations and can have unwanted drug interactions, potentially causing more harm than good. Many supplements have no proven efficacy in treating depression and are marketed with the intent of appearing more “natural” than traditional medications. Individuals who experience success with untested supplements may only be experiencing placebo-like effects or may be paid salespeople, intentionally trying to con vulnerable people seeking to treat their depression. Social media and online advertising have attracted the attention of numerous scam companies that only want to sell useless products to as many people as they are able.

Long-term treatment may be required for people suffering from three or more major depressive episodes in their lifetime, chronic episodes lasting more than two years, or a history of self-harm while in the throes of depression. Despite this, chronic depression does not have to mean a life of unhappiness. Many patients on lifelong antidepressant treatment can go for years without any symptoms whatsoever. Consistent dialogue with a medical professional about how and when to stop treatments is important to prevent relapse. Suddenly quitting treatment puts the patient at risk of medication side-effects and may not be wise with all forms of therapy.

Ultimately, depression is a medical condition much like any other. It has proven treatments and is no one’s “fault”. Management by a trained medical professional is the most effective way of treating depression, not online supplements or simply trying to “deal with it”. Treatment for depression is readily available, so why not get help?

1. https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.157.10.1552?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&
2. https://www.apa.org/depression-guideline/guideline.pdf
3. https://bmjopen.bmj.com/content/bmjopen/3/4/e002542.full.pdf
4. https://www.ncbi.nlm.nih.gov/pubmed/30098649 (This article does not have open availability to the public at this time; this article was reviewed by the author using institutional access through the IU School of Medicine. Additionally, the abstract is vague and not written in a way that is readily understood by most laypersons.)