Major Depression (Major Depressive Disorder)

This page focuses on how major depression is diagnosed, classified and treated step by step. For a general overview of causes and symptoms, see depression.

Major depressive disorder criteria

Under the DSM-5-TR, the manual used by US mental health professionals, a major depressive episode requires at least 5 of these 9 symptoms, present most of the day, nearly every day, for at least 2 weeks. At least one must be depressed mood or loss of interest.

1. Depressed mood (in children and teens, this can be irritability)
2. Markedly reduced interest or pleasure in almost all activities (anhedonia)
3. Significant weight or appetite change, without dieting
4. Insomnia or sleeping too much
5. Visible restlessness or slowed movement and speech
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Poor concentration or indecisiveness
9. Recurrent thoughts of death, suicidal thoughts, plans or attempts

The symptoms must cause real distress or impairment at work, at home or socially. They must not be due to a substance, medicine or medical condition, and there must never have been a manic or hypomanic episode (which would point to bipolar disorder).

Single episode or recurrent

A diagnosis is recorded as a single episode or recurrent (two or more episodes separated by at least 2 months of feeling well). The risk of another episode rises with each one, which affects how long treatment continues.

How severity is rated

The PHQ-9 is a 9-question form based on the criteria above. Scores of 10 or more usually prompt a full assessment. It is used both to screen and to track response to treatment. The US Preventive Services Task Force recommends depression screening for all adults, including during and after pregnancy.

Subtypes (specifiers)

• With anxious distress: tension, restlessness, worry and fear something awful will happen. Common, and linked to higher suicide risk.
• With melancholic features: near-total loss of pleasure, worse mood in the morning, early waking, marked weight loss and guilt. Often responds well to medicines and ECT.
• With atypical features: mood lifts with good events, overeating, oversleeping, heavy limbs and sensitivity to rejection.
• With psychotic features: delusions or hallucinations, usually guilt- or illness-themed. Needs combined antidepressant and antipsychotic treatment or ECT.
• With peripartum onset: starting in pregnancy or within 4 weeks after birth. See postpartum depression.
• With seasonal pattern: episodes that regularly start in fall or winter (seasonal affective disorder).
• With mixed features: some manic symptoms during depression, which raises concern for bipolar disorder.

What else doctors rule out

• Medical causes: hypothyroidism, anemia, vitamin B12 deficiency, sleep apnea, and neurological illness such as stroke or Parkinson disease. Blood tests often include a blood count and thyroid function.
• Substances and medicines: alcohol, cannabis, steroids, some acne and hormonal medicines.
• Other mental health conditions: bipolar disorder, persistent depressive disorder (dysthymia), grief, adjustment disorder and PTSD.

Major depression treatment

Treatment choice depends on severity, past response and your preference.

Mild to moderate

• Psychotherapy: cognitive behavioral therapy (CBT), behavioral activation, interpersonal therapy and problem-solving therapy are as effective as antidepressants for many people.
• Antidepressants: an option, especially with previous good response or personal preference.
• Exercise, structured and supervised, has good evidence as part of treatment.

Moderate to severe

A combination of psychotherapy and an antidepressant works better than either alone.

How antidepressants are used

• First choices are usually SSRIs (such as sertraline, escitalopram) or other newer drugs such as SNRIs, bupropion or mirtazapine.
• Some benefit, often sleep or energy, may appear in 1 to 2 weeks. Full effect takes 4 to 8 weeks.
• After recovery, continue for at least 6 to 12 months to prevent relapse. People with recurrent episodes may be advised to continue for 2 years or longer.
• Stop only with medical guidance and a gradual taper, to avoid withdrawal symptoms.
• Antidepressants carry an FDA boxed warning about increased suicidal thoughts in people under 25 in the first weeks. Close follow-up in this period is standard.

Treatment-resistant depression

If two adequate trials of antidepressants have not worked, options include:

• Raising the dose, switching to a different class, or adding psychotherapy
• Augmentation with lithium, certain antipsychotics (such as aripiprazole) or a second antidepressant
• Esketamine nasal spray, given under supervision in a certified clinic
• Transcranial magnetic stimulation (TMS), using magnetic pulses over the scalp in daily sessions over several weeks
• Electroconvulsive therapy (ECT): the most effective treatment for severe, psychotic or life-threatening depression, given under anesthesia

Outlook

Most people with major depression improve with treatment, and many reach full remission. The aim is remission (minimal symptoms), not just partial response, because leftover symptoms raise relapse risk. Ongoing therapy, staying on medicine long enough, regular sleep, activity and early action on warning signs all reduce recurrence.

Frequently asked questions

What is the difference between depression and major depression?

"Depression" is often used loosely for low mood. Major depression, or major depressive disorder, is a specific diagnosis requiring at least 5 of 9 symptoms, including depressed mood or loss of interest, nearly every day for 2 weeks or more, with real impact on daily life.

How long does a major depressive episode last?

Without treatment, an episode commonly lasts several months, and sometimes a year or longer. With effective treatment, many people improve within 6 to 12 weeks. Treatment usually continues for 6 to 12 months after feeling well to prevent the episode returning.

What does recurrent major depressive disorder mean?

It means you have had two or more separate major depressive episodes, with at least 2 months of feeling well in between. Recurrent depression often calls for longer-term treatment, such as continuing an antidepressant or ongoing therapy, and a plan for spotting early warning signs.

What is treatment-resistant depression?

Depression is usually called treatment-resistant when it has not responded to at least two antidepressants given at an adequate dose for an adequate time. It is still treatable: options include augmentation medicines, psychotherapy, esketamine, transcranial magnetic stimulation and electroconvulsive therapy.

Can major depression go away without treatment?

Some episodes do lift on their own over months, but untreated depression lasts longer, recurs more often and carries a risk of suicide. Treatment shortens episodes and lowers the chance of relapse, so it is worth seeking help even if you expect it to pass.