The Depths of Major Depressive Disorder: A Journey through Darkness

It is important to first understand what is depression before discussing and talking about MDD (Major Depressive Disorder) which is a very serious type of depression. It is very common for people to say that they are feeling depressed, but, feeling depressed and suffering from depression are two majorly different things. You might feel depressed for a day because the test you appeared for did not go as well as expected. However, being in depression means experiencing depressive symptoms for more than 2 weeks. An individual is diagnosed to be in depression only if they are experiencing those symptoms for more than two weeks consistently.

Signs and Symptoms of Depression

A major depressive episode is characterized by five or more symptoms present during two weeks, indicating a change from previous functioning. These symptoms include:

• a depressed mood,
• diminished interest or pleasure in activities,
• significant weight loss,
• insomnia,
• psychomotor agitation,
• fatigue,
• feelings of worthlessness or excessive guilt,
• diminished ability to think or concentrate,
• recurrent thoughts of death,
• recurrent suicidal ideation,
• As well as a notable disturbance in social, professional, or other important areas of functioning, or distress.

The incident cannot be linked to any other medical condition or the physiological effects of a substance. Responses to significant loss, such as bereavement, financial ruin, natural disasters, or serious medical illnesses or disabilities, may include feelings of intense sadness, rumination, insomnia, poor appetite, and weight loss. However, the presence of a major depressive episode in addition to the normal response to a significant loss should be carefully considered, requiring clinical judgment depending on the person’s past and societal expectations of how one should exhibit grief in the wake of loss.

According to clinical psychologist Abhilasha Agarwal

There are several reasons for depression, the first could be biological; low levels of serotonin in the brain may lead to depressive symptoms in the person. Psychiatric family history may also contribute to depressive symptoms such as if any of the parents or first-degree relative has or had a mental illness, then it can affect the children as well. Another reason could be social; if people face adverse experiences in childhood and adolescence, they may have a high vulnerability for developing depression in adulthood.

Other reasons could be psychological; poor impulse control, low-stress tolerance, negative view of themselves, others, and the world, having unrealistic expectations from self or others, and a tendency to blame oneself for anything that goes wrong. Also, certain sudden life changes such as breaking up in a relationship, losing jobs, or divorce can also cause depressive symptoms. People who have poor social and family support or who have no friends are more likely to suffer from depression. Depression is not a disease to easily detect; most people suffer from it, but they have no idea about it.

Major Depressive Disorder

A major depressive episode is often described as depressed, sad, hopeless, discouraged, or “down in the dumps.” It can be elicited by interviews, facial expressions, or somatic complaints. Some individuals may report increased irritability, such as persistent anger or blaming others. In children and adolescents, an irritable or cranky mood may develop instead of a sad or dejected mood. Diminished interest or pleasure in usual activities is also present, with individuals reporting less interest in hobbies or not caring anymore. In some cases, there is a significant reduction from previous levels of sexual interest or desire.

Depressed individuals may experience appetite changes, which can be either reduced or increased. Some may force themselves to eat, while others may eat more and crave specific foods. Severe appetite changes can lead to significant weight loss or gain, or failure to make expected weight gains in children

Sleep disturbances can take the form of difficulty sleeping or excessive sleep. Insomnia can take the form of middle or terminal insomnia, and initial insomnia may also occur. Oversleeping (hypersomnia) can lead to prolonged sleep episodes at night or increased daytime sleep. Sometimes, the reason for seeking treatment is for disturbed sleep.

Psychomotor Changes and Cognitive Impairment

Psychomotor changes involve agitation (slow speech, thinking, and movement of the body; increased halts before responding, speech that is decreased in volume, inflection, number, or variety of information, or muteness) or retardation (slow speech, thinking, and body actions; increased pacing, hand wringing, or pulling or brushing of the skin, clothing, or other things). The psychomotor disturbance or retardation must be significant enough for others to notice it and not just experience subjective feelings. Psychomotor dysfunction (i.e., psychomotor retardation or agitation) is more common in those with a history of the other.

Decreased energy, tiredness, and fatigue are common symptoms of major depressive disorder, which can lead to impaired efficiency in tasks and a sense of worthlessness or guilt. This can occur during acute episodes or when remission is incomplete. The individual may misinterpret neutral or trivial events as evidence of personal defects and have an exaggerated sense of responsibility for untoward events.

The sense of worthlessness or guilt may be delusional, such as believing they are personally responsible for world poverty. Blaming oneself for being sick and failing to meet occupational or interpersonal responsibilities due to depression is common and, unless delusional, is not considered sufficient to meet this criterion. This symptom accounts for much of the impairment resulting from major depressive disorder. Impaired ability to think, concentrate, or make minor decisions is common, with some individuals appearing easily distracted or complaining of memory difficulties. Children may experience a precipitous drop in grades due to poor concentration, while older people may have memory difficulties that may be mistaken for early signs of dementia.

Risk Factors That Are Prone to MDD

• Negative affectivity (neuroticism) is a significant risk factor for major depressive disorder, with high levels, making individuals more likely to develop depressive episodes in response to stressful life events.
• Adverse childhood experiences, particularly multiple and diverse types, are also potent risk factors, particularly for women.
• Other social determinants of mental health, such as low income, limited formal education, racism, and discrimination, are associated with higher risk.
• Stressful life events are known precipitants of major depressive episodes, but their presence or absence does not provide a useful guide for prognosis or treatment selection.
• Women are disproportionately affected by major risk factors for depression across their lives, including interpersonal trauma.
• Genetic and physiological risk is two- to fourfold higher for first-degree family members of individuals with major depressive disorder.

According to Sucheta Mishra, a clinical psychologist

Depression has three levels: mild, moderate, and severe depression. In the core features of depression, usually, people will have a very low mood that they find very hard to get out of. They will have a loss of energy and loss of interest in things they previously enjoyed.

It is often difficult to do day-to-day activities due to fatigue. Apart from this, there are several other symptoms. For example, difficulties with paying attention and focusing, and their sleep could be disturbed. They don’t feel like eating as usual. Then they might also have thoughts about harming themselves. So all of these are symptoms of depression, and if a person is having crippling depression, that means that they are very depressed and cannot even do their basic activities. In such a situation, it is better to visit a psychiatrist, where they might require medication. 

Once the severity comes down and functioning improves a little bit more, then they can look at other psychological therapies. For example, cognitive-behavioral therapy will help them change their negative thoughts and learn ways to manage depression. One of the key symptoms of depression is that people start thinking constantly negatively about the world, themselves, and the future. Through psychological therapy, people can be taught to see themselves realistically and learn skills to cope with their depression. Family support is very essential during this time.

Treatment for Severe Depression

Although psychotherapy is an important part of treatment for depression. In cases with severe depression, it might not be beneficial alone. As we discussed the symptoms are life-threatening in cases of severe depression, the psychotherapy cannot help the patient alone get better. Such patients are usually given the medicated treatment first to reduce the severe symptoms and then the psychotherapeutic treatment is continued along with medicines.

Antidepressants are available in various types, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), atypical antidepressants, tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and other medications.

SSRIs are safer and generally cause fewer side effects, while SNRIs include duloxetine, venlafaxine, and levomilnacipran. Atypical antidepressants include bupropion, mirtazapine, trazodone, and vortioxetine. Tricyclics are effective but can cause severe side effects, so they are usually prescribed after an SSRI has not improved. Other medications, such as mood stabilizers, antipsychotics, and anti-anxiety and stimulant medications, can be added to enhance antidepressant effects.

Note: We recommend taking medication based on the advice of mental health experts.