Major Depression

  • What Is It?
  • Symptoms
  • Diagnosis
  • Expected Duration
  • Treatment
  • When To Call A Professional
  • Prognosis
  • Prevention
  • What Is It?

    Major depression is an illness that involves the way a person thinks and feels. Depression usually involves extreme sadness or a sense of despair, but it can be felt as irritability, a lack of pleasure or interest in pleasurable activities, or a loss of energy. Depression is considered a mood disorder. It comes in many forms with a wide variety of symptoms, and the symptoms can vary significantly between different people. Major depression is more than just a passing blue mood, a “bad day,” or temporary sadness over a specific event. The mood changes that come with major depression last for at least two weeks and usually much longer.

    Depression usually affects a person’s ability to work, sleep, eat and enjoy leisure activities. Many people with depression also have anxiety and tend to worry more about their physical health. They may have problems in their relationships and with sexual functioning. People with depression are more likely to abuse alcohol or other substances.

    The cause of major depression is not clear, but it probably involves chemicals called neurotransmitters that carry messages between brain cells. Changes in some hormones may play a role in depression. An episode of depression can be triggered by a stressful life event, such as the death of a loved one. But in many cases, depression does not appear to be related to a specific event. Major depression may occur just once in a person’s life or may return periodically throughout life. Some people who have repeated episodes of major depression also have a long pattern of a milder depressed mood called dysthymia. If a woman has a major depressive episode within a month after delivering a baby, it is called postpartum depression. Depression also can occur mainly during the winter months. This condition is called seasonal affective disorder, or SAD.

    Episodes of depression can occur at any age. Depression affects women twice as often as men. People who have a family member with major depression are more likely to develop depression or drinking problems.

    When major depression alternates with periods of intense happiness and energy, the illness is called bipolar disorder.


    A depressed person may notice a weight gain or loss, eat more or less than usual, have difficulty concentrating, and have trouble sleeping or sleep more than usual. He or she may feel tired and have no energy for work or play. The person can appear slowed down or agitated and restless. The symptoms can be quite noticeable to others.

    Perhaps the most painful and most dangerous symptom of this illness is an unshakable feeling of worthlessness and guilt. The person may feel guilty about a specific life experience or may feel general guilt not related to anything specific.

    Small burdens or obstacles may appear impossible to manage. If pain and self-criticism become great enough, it can lead to feelings of hopelessness, self-destructive behavior, or thoughts of death and suicide. The vast majority of people who suffer severe depression do not attempt or commit suicide, but they are more likely to do so.

    People with major depression often have distorted thinking. For example, they are likely to be pessimistic out of proportion with the reality of their situation. Sometimes, the thinking of a depressed person becomes psychotic, that is, the person has great difficulty recognizing reality. Sometimes, depressed people develop delusions (false beliefs) or hallucinations (false perceptions).

    Symptoms of major depression include:

    • Distinctly depressed or irritable mood
    • Loss of interest or pleasure
    • Decreased or increased weight or appetite
    • Increased or decreased sleep
    • Appearing slowed or agitated
    • Fatigue and loss of energy
    • Feeling worthless or guilty
    • Poor concentration
    • Indecisiveness
    • Thoughts of death, suicide attempts or plans


    A primary care physician or a mental health professional usually can diagnose depression by asking questions about medical history and symptoms. Major depression is diagnosed when a person has many of the symptoms listed above lasting at least two weeks. Many people with depression do not seek treatment because of society’s attitudes about depression. The person may feel the depression is his or her fault or may worry about what others will think. The depression itself may distort a person’s ability to recognize the problem.

    There are no specific tests for depression. However, it is important to be evaluated by a primary care physician to make sure the problems are not being caused by a medical condition or medication.

    Expected Duration

    Episodes of major depression last on average four to eight months, but they can last for any length of time. Symptoms can vary in intensity during an episode. If depression is not treated, it can become chronic (long-lasting). Treatment can shorten the length and severity of a depressive episode.


    There is no way to prevent major depression, but detecting it early can diminish symptoms and help to prevent the illness from returning.


    A combination of psychotherapy and medication is most helpful. The most commonly prescribed antidepressants are in the group known as selective serotonin reuptake inhibitors (SSRIs). They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa). They are fairly easy to take and relatively safe compared to previous generations of antidepressants.

    No medication is without side effects. SSRIs are known to cause problems with sexual functioning, some nausea, and an increase in anxiety in the early stages of treatment. Concerns about an increased risk of suicide in people taking SSRIs have been overblown. However, a very small number of patients taking these medications may feel worse rather than better. All troubling changes should be reported immediately to your doctor.

    Other newer and effective antidepressants are bupropion (Wellbutrin), venlafaxine (Effexor) and mirtazapine (Remeron). The older classes of antidepressants, tricyclic antidepressants and monoamine inhibitors, are still in use and can be very effective for people who have not responded to other treatments.

    It usually takes at least two to six weeks of taking any antidepressant to see improvement. Sometimes, it will take up to a few months to find a proper dose and for the full positive effect to be seen.

    Sometimes, two different antidepressants are prescribed together to enhance the effect. Or, a medication from the class called mood stabilizers, such as lithium (sold under several brand names) or valproic acid (Depakene, Depakote), is added. If psychotic symptoms are present, a medication from the class known as antipsychotics is usually prescribed. These include risperidone (Risperdal) and olanzapine (Zyprexa, Zydis).

    A number of psychotherapy techniques may be helpful depending on several factors, including the events that may have contributed to the problem, the availability of family and other social support, and personal preference. It is important to get education about depression and what support is available. Cognitive behavioral therapy is designed to help you recognize the unreasonableness of fearful thinking and teach you techniques for controlling your symptoms. Psychodynamic, insight-oriented or interpersonal psychotherapy can help a person to sort out conflicts in important relationships or explore the history behind the symptoms.

    In some situations, a treatment called electroconvulsive therapy (ECT) can be a life-saving option. This treatment is controversial, but effective. In ECT, an electrical impulse to the person’s brain causes a seizure. The patient is under anesthesia and is monitored carefully. Medication is given before the procedure to prevent any outward signs of convulsions, which helps to prevent injury. Improvement is seen gradually over a period of days to weeks after the treatment. ECT is the quickest and most effective treatment for the most severe forms of depression, and the risks are similar to other antidepressant treatments.

    When To Call A Professional

    Depression is a painful and potentially dangerous illness, so you should contact a health care professional if you have any suspicion that you or a loved one is depressed.


    Treatment of depression has become quite sophisticated and effective. The prognosis with treatment is excellent. The intensity of symptoms and the frequency of episodes often are significantly reduced. Many people recover completely.

    When treatment is successful, it is important to stay in close touch with your doctor or therapist, because maintenance treatment is often required to prevent depression from returning.

    Johns Hopkins patient information

    Last revised:

    Diseases and Conditions Center

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