Depression (major depressive disorder)

Diagnosis

Your doctor may determine a diagnosis of depression based on:

• Physical exam. Your doctor may do a physical exam and ask questions about your health. In some cases, depression may be linked to an underlying physical health problem.
• Lab tests. For example, your doctor may do a blood test called a complete blood count or test your thyroid to make sure it's functioning properly.
• Psychiatric evaluation. Your mental health professional asks about your symptoms, thoughts, feelings and behavior patterns. You may be asked to fill out a questionnaire to help answer these questions.
• DSM-5. Your mental health professional may use the criteria for depression listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Types of depression

Symptoms caused by major depression can vary from person to person. To clarify the type of depression you have, your doctor may add one or more specifiers. A specifier means that you have depression with specific features, such as:

• Anxious distress — depression with unusual restlessness or worry about possible events or loss of control
• Mixed features — simultaneous depression and mania, which includes elevated self-esteem, talking too much and increased energy
• Melancholic features — severe depression with lack of response to something that used to bring pleasure and associated with early morning awakening, worsened mood in the morning, major changes in appetite, and feelings of guilt, agitation or sluggishness
• Atypical features — depression that includes the ability to temporarily be cheered by happy events, increased appetite, excessive need for sleep, sensitivity to rejection, and a heavy feeling in the arms or legs
• Psychotic features — depression accompanied by delusions or hallucinations, which may involve personal inadequacy or other negative themes
• Catatonia — depression that includes motor activity that involves either uncontrollable and purposeless movement or fixed and inflexible posture
• Peripartum onset — depression that occurs during pregnancy or in the weeks or months after delivery (postpartum)
• Seasonal pattern — depression related to changes in seasons and reduced exposure to sunlight

Other disorders that cause depression symptoms

Several other disorders, such as those below, include depression as a symptom. It's important to get an accurate diagnosis, so you can get appropriate treatment.

• Bipolar I and II disorders. These mood disorders include mood swings that range from highs (mania) to lows (depression). It's sometimes difficult to distinguish between bipolar disorder and depression.
• Cyclothymic disorder. Cyclothymic (sy-kloe-THIE-mik) disorder involves highs and lows that are milder than those of bipolar disorder.
• Disruptive mood dysregulation disorder. This mood disorder in children includes chronic and severe irritability and anger with frequent extreme temper outbursts. This disorder typically develops into depressive disorder or anxiety disorder during the teen years or adulthood.
• Persistent depressive disorder. Sometimes called dysthymia (dis-THIE-me-uh), this is a less severe but more chronic form of depression. While it's usually not disabling, persistent depressive disorder can prevent you from functioning normally in your daily routine and from living life to its fullest.
• Premenstrual dysphoric disorder. This involves depression symptoms associated with hormone changes that begin a week before and improve within a few days after the onset of your period, and are minimal or gone after completion of your period.
• Other depression disorders. This includes depression that's caused by the use of recreational drugs, some prescribed medications or another medical condition.

Treatment

Medications and psychotherapy are effective for most people with depression. Your primary care doctor or psychiatrist can prescribe medications to relieve symptoms. However, many people with depression also benefit from seeing a psychiatrist, psychologist or other mental health professional.

If you have severe depression, you may need a hospital stay, or you may need to participate in an outpatient treatment program until your symptoms improve.

Here's a closer look at depression treatment options.

Medicines

Many types of antidepressants are available, including those below. Each medicine can cause side effects and interact with other medicines. Talk with your healthcare professional or pharmacist about the benefits and risks of your medicine.

• Selective serotonin reuptake inhibitors (SSRIs). Healthcare professionals often prescribe an SSRI as a first treatment for depression. SSRIs generally cause fewer side effects than older types of antidepressants. Examples include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft) and vilazodone (Viibryd).
• Serotonin-norepinephrine reuptake inhibitors (SNRIs). SNRIs include desvenlafaxine (Pristiq), duloxetine (Cymbalta, Drizalma Sprinkle), levomilnacipran (Fetzima) and venlafaxine (Effexor XR).
• Atypical antidepressants. These medications don't fit into any of the other antidepressant categories. They include bupropion (Wellbutrin SR, Wellbutrin XL, Aplenzin, Forfivo XL), mirtazapine (Remeron), nefazodone, trazodone and vortioxetine (Trintellix). Dextromethorphan-bupropion (Auvelity) is a newer option for adults.
• Tricyclic antidepressants. These antidepressants include imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin, trimipramine (Surmontil), desipramine (Norpramin) and protriptyline (Vivactil). These medicines can be effective, but they tend to cause more side effects than newer antidepressants. For this reason, healthcare professionals generally do not use them as a first treatment for depression.
• Monoamine oxidase inhibitors (MAOIs). MAOIs include tranylcypromine (Parnate), phenelzine (Nardil), isocarboxazid (Marplan) and the selegiline skin patch (Emsam). Healthcare professionals generally prescribe MAOIs when other antidepressants have not helped because MAOIs can cause serious interactions. People who take MAOIs must avoid foods high in tyramine — such as certain cheeses, pickles and wines — and certain medicines and supplements. These interactions can cause a dangerous rise in blood pressure. The lowest-dose selegiline patch may not require dietary restrictions, but higher-dose patches do. MAOIs must not be taken with SSRIs or certain other medicines.
• Medicines that may be added to antidepressants. If an antidepressant does not help enough, your healthcare professional may recommend adding another medicine. Options may include another antidepressant, a mood stabilizer or an antipsychotic medicine approved as an add-on treatment for depression. Examples of add-on antipsychotic medicines include aripiprazole (Abilify), brexpiprazole (Rexulti), cariprazine (Vraylar), lumateperone (Caplyta) and quetiapine extended-release (Seroquel XR).

Finding the right medicine

If a family member has responded well to an antidepressant, it may be one that could help you. Or you may need to try several medicines or a combination of medicines before you find one that works. This requires patience, as some medicines need several weeks or longer to take full effect and for side effects to ease as your body adjusts.

Inherited traits play a role in how antidepressants affect you. In some cases, where available, results of genetic tests, which are done by a blood test or a cheek swab, may offer clues about how your body may respond to a particular antidepressant. But other variables besides genetics can affect your response to medicine.

Risks of abruptly stopping medicine

Don't stop taking an antidepressant without talking to your doctor first. Antidepressants are not considered addictive, but sometimes physical dependence, which is different from addiction, can happen.

Stopping treatment abruptly or missing several doses can cause withdrawal-like symptoms, and quitting suddenly may cause a sudden worsening of depression. Work with your healthcare professional to gradually and safely reduce your dose.

Antidepressants and pregnancy

If you're pregnant, planning to become pregnant or breastfeeding, talk with your healthcare professional about your antidepressant. Some antidepressants may pose risks during pregnancy or breastfeeding. But stopping an antidepressant suddenly or leaving depression untreated also may pose risks. Your healthcare professional can help you weigh the benefits and risks of treatment and choose the safest option for you and your baby.

FDA alert on antidepressants

Antidepressants are generally safe when taken as directed. But the U.S. Food and Drug Administration (FDA) requires all antidepressants to carry a warning. In some cases, children, teenagers and young adults under age 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior. If you or someone you know has suicidal thoughts when taking an antidepressant, immediately contact a healthcare professional or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long term by improving mood.

Psychotherapy

Psychotherapy is a general term for treating depression by talking about your condition and related issues with a mental health professional. Psychotherapy is also known as talk therapy or psychological therapy.

Different types of psychotherapy can be effective for depression, such as cognitive behavioral therapy or interpersonal therapy. Your mental health professional may also recommend other types of therapies. Psychotherapy can help you:

• Adjust to a crisis or other current difficulty
• Identify negative beliefs and behaviors and replace them with healthy, positive ones
• Explore relationships and experiences, and develop positive interactions with others
• Find better ways to cope and solve problems
• Identify issues that contribute to your depression and change behaviors that make it worse
• Regain a sense of satisfaction and control in your life and help ease depression symptoms, such as hopelessness and anger
• Learn to set realistic goals for your life
• Develop the ability to tolerate and accept distress using healthier behaviors

Alternate formats for therapy

Formats for depression therapy as an alternative to face-to-face office sessions are available and may be an effective option for some people. Therapy can be provided, for example, as a computer program, by online sessions, or using videos or workbooks. Programs can be guided by a therapist or be partially or totally independent.

Before you choose one of these options, discuss these formats with your therapist to determine if they may be helpful for you. Also, ask your therapist if he or she can recommend a trusted source or program. Some may not be covered by your insurance and not all developers and online therapists have the proper credentials or training.

Smartphones and tablets that offer mobile health apps, such as support and general education about depression, are not a substitute for seeing your doctor or therapist.

Hospital and residential treatment

In some people, depression is so severe that a hospital stay is needed. This may be necessary if you can't care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves.

Partial hospitalization or day treatment programs also may help some people. These programs provide the outpatient support and counseling needed to get symptoms under control.

Other treatment options

For some people, other procedures, sometimes called brain stimulation therapies, may be suggested:

• Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain to impact the function and effect of neurotransmitters in your brain to relieve depression. ECT is usually used for people who don't get better with medications, can't take antidepressants for health reasons or are at high risk of suicide.
• Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven't responded to antidepressants. During TMS, a treatment coil placed against your scalp sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

Depression generally isn't a disorder that you can treat on your own. But in addition to professional treatment, these self-care steps can help:

• Stick to your treatment plan. Don't skip psychotherapy sessions or appointments. Even if you're feeling well, don't skip your medications. If you stop, depression symptoms may come back, and you could also experience withdrawal-like symptoms. Recognize that it will take time to feel better.
• Learn about depression. Education about your condition can empower you and motivate you to stick to your treatment plan. Encourage your family to learn about depression to help them understand and support you.
• Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your depression symptoms. Make a plan so that you know what to do if your symptoms get worse. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Ask relatives or friends to help watch for warning signs.
• Avoid alcohol and recreational drugs. It may seem like alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your doctor or therapist if you need help with alcohol or substance use.
• Take care of yourself. Eat healthy, be physically active and get plenty of sleep. Consider walking, jogging, swimming, gardening or another activity that you enjoy. Sleeping well is important for both your physical and mental well-being. If you're having trouble sleeping, talk to your doctor about what you can do.

Alternative medicine

Alternative medicine is the use of a nonconventional approach instead of conventional medicine. Complementary medicine is a nonconventional approach used along with conventional medicine — sometimes called integrative medicine.

Make sure you understand the risks as well as possible benefits if you pursue alternative or complementary therapy. Don't replace conventional medical treatment or psychotherapy with alternative medicine. When it comes to depression, alternative treatments aren't a substitute for medical care.

Supplements

Examples of supplements that are sometimes used for depression include:

• St. John's wort. Although this herbal supplement isn't approved by the Food and Drug Administration (FDA) to treat depression in the U.S., it may be helpful for mild or moderate depression. But if you choose to use it, be careful — St. John's wort can interfere with a number of medications, such as heart drugs, blood-thinning drugs, birth control pills, chemotherapy, HIV/AIDS medications and drugs to prevent organ rejection after a transplant. Also, avoid taking St. John's wort while taking antidepressants because the combination can cause serious side effects.
• SAMe. Pronounced "sam-E," this dietary supplement is a synthetic form of a chemical that occurs naturally in the body. The name is short for S-adenosylmethionine (es-uh-den-o-sul-muh-THIE-o-neen). SAMe isn't approved by the FDA to treat depression in the U.S. It may be helpful, but more research is needed. SAMe may trigger mania in people with bipolar disorder.
• Omega-3 fatty acids. These healthy fats are found in cold-water fish, flaxseed, flax oil, walnuts and some other foods. Omega-3 supplements are being studied as a possible treatment for depression. While considered generally safe, in high doses, omega-3 supplements may interact with other medications. More research is needed to determine if eating foods with omega-3 fatty acids can help relieve depression.

Nutritional and dietary products aren't monitored by the FDA the same way medications are. You can't always be certain of what you're getting and whether it's safe. Also, because some herbal and dietary supplements can interfere with prescription medications or cause dangerous interactions, talk to your doctor or pharmacist before taking any supplements.

Mind-body connections

Integrative medicine practitioners believe the mind and body must be in harmony for you to stay healthy. Examples of mind-body techniques that may be helpful for depression include:

• Acupuncture
• Relaxation techniques such as yoga or tai chi
• Meditation
• Guided imagery
• Massage therapy
• Music or art therapy
• Spirituality
• Aerobic exercise

Relying solely on these therapies is generally not enough to treat depression. They may be helpful when used in addition to medication and psychotherapy.

Coping and support

Talk with your doctor or therapist about improving your coping skills, and try these tips:

• Simplify your life. Cut back on obligations when possible, and set reasonable goals for yourself. Give yourself permission to do less when you feel down.
• Write in a journal. Journaling, as part of your treatment, may improve mood by allowing you to express pain, anger, fear or other emotions.
• Read reputable self-help books and websites. Your doctor or therapist may be able to recommend books or websites to read.
• Locate helpful groups. Many organizations, such as the National Alliance on Mental Illness (NAMI) and the Depression and Bipolar Support Alliance, offer education, support groups, counseling and other resources to help with depression. Employee assistance programs and religious groups also may offer help for mental health concerns.
• Don't become isolated. Try to participate in social activities, and get together with family or friends regularly. Support groups for people with depression can help you connect to others facing similar challenges and share experiences.
• Learn ways to relax and manage your stress. Examples include meditation, progressive muscle relaxation, yoga and tai chi.
• Structure your time. Plan your day. You may find it helps to make a list of daily tasks, use sticky notes as reminders or use a planner to stay organized.
• Don't make important decisions when you're down. Avoid decision-making when you're feeling depressed, since you may not be thinking clearly.

Preparing for your appointment

You may see your primary care doctor, or your doctor may refer you to a mental health professional. Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Any symptoms you've had, including any that may seem unrelated to the reason for your appointment
• Key personal information, including any major stresses or recent life changes
• All medications, vitamins or other supplements that you're taking, including dosages
• Questions to ask your doctor or mental health professional

Take a family member or friend along, if possible, to help you remember all of the information provided during the appointment.

Some basic questions to ask your doctor include:

• Is depression the most likely cause of my symptoms?
• What are other possible causes for my symptoms?
• What kinds of tests will I need?
• What treatment is likely to work best for me?
• What are the alternatives to the primary approach that you're suggesting?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a psychiatrist or other mental health professional?
• What are the main side effects of the medications you're recommending?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor will likely ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to focus on. Your doctor may ask:

• When did you or your loved ones first notice your symptoms of depression?
• How long have you felt depressed? Do you generally always feel down, or does your mood fluctuate?
• Does your mood ever swing from feeling down to feeling intensely happy (euphoric) and full of energy?
• Do you ever have suicidal thoughts when you're feeling down?
• Do your symptoms interfere with your daily life or relationships?
• Do you have any blood relatives with depression or another mood disorder?
• What other mental or physical health conditions do you have?
• Do you drink alcohol or use recreational drugs?
• How much do you sleep at night? Does it change over time?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?