Portraits of Major Depressive Disorder

Sarah woke up late—again. No morning coffee. No morning reading or jog (as she has vowed to start doing several times). And she got to work 5 minutes late for the third time this month, which wouldn’t be such an issue if she didn’t spend the next few hours beating herself up about it. Everything feels undone: hopelessly incomplete and pointless. Netflix used to ease the pain, but now, even binge-watching Stranger Things seems monotonous.

Deshaun’s favorite thing used to be walking around the city with headphones in, simply enjoying his surroundings and watching the buzz of human activity play out to a soundtrack of his choosing. Almost three years ago, however, he was hit by a car. The driver didn’t notice the red light, but noticed his mistake enough to speed off, leaving Deshaun to the mercy of a stranger who called an ambulance. One knee surgery and several months of physical therapy later, he was able to take up his walking routine again. Except, he didn’t want to. In fact, he rarely leaves his apartment for days, and often calls out of work for no good reason.

Jump to: Portraits | Definition | Diagnosis, Signs and Symptoms | Causes | Treatment | Action Steps | Get Help

What Is Major Depressive Disorder?

Major depressive disorder affects around 40 million Americans and 350 million people worldwide. It can be incredibly debilitating for individuals suffering with the illness, as well as difficult for those around them—especially when an individual with depression has yet to admit to him or herself that the problem exists.

Who’s at Risk?

Depression (and its various forms) affects all ages, genders, races, nationalities and occupations. It can hit once out of the blue, appear intermittently, or (in rare cases) be a lifelong affliction. Depressed mood can be mild—the blues, the blahs, the doldrums—or severe enough to cripple or kill.

There are few things as frightening as going through a major depressive episode for the first time. But no matter how bad it is, depression will almost always pass—there wouldn’t be so many successful people claiming histories of depression if that weren’t the case. In fact, depression is one of the most treatable mental illnesses we know of and the vast majority of people who experience depression will recover fully. If, right now, you’re reading this and you feel hopeless, remember: Feelings aren’t facts. Your brain can and will lie to you. And there are things you can do to help yourself.

Jump to: Portraits | Definition | Diagnosis, Signs and Symptoms | Causes | Treatment | Action Steps | Get Help

Diagnosing Major Depressive Disorder — Signs and Symptoms

The diagnosis of major depressive disorder largely depends upon an individual’s self-report of his or her symptoms to a licensed mental health professional. Attempting to self-diagnose based on your own research, however, is not recommended—it can lead to confusion and heightened anxiety. Instead, understanding the terms, symptoms, and causes of mood disorders can help you better acknowledge what might be going on internally and aid you in speaking with a professional.

In order to be diagnosed with major depressive disorder, five or more of the symptoms listed (including at least one of the first two) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) must be present within the same two-week period and must present a noticeable change in daily function (professionally and/or personally). The symptoms must also not be clearly caused by another medical condition or substance:

1. Depressed mood, most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation from others (e.g., appears tearful). Note: In children and adolescents, this can be irritable mood.

2. Markedly diminished interest or pleasure in all or most activities throughout the day, nearly every day, as indicated by subjective or objective account.

3. Significant weight loss or weight gain (e.g., a change of more than 5% of his or her body weight in a month, or a decrease or increase in appetite nearly every day). Note: In children, consider failure to make expected weight gain.

4. Insomnia or hypersomnia, nearly every day.

5. Psychomotor agitation nearly every day. This is observable by others, not merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive/inappropriate guilt (which may be delusional) nearly every day.

8. Diminished ability to think, concentrate, or make decisions nearly every day as self-reported or observed objectively.

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation about a specific plan, or a suicide attempt or a specific plan for committing suicide.

Jump to: Portraits | Definition | Diagnosis, Signs and Symptoms | Causes | Treatment | Action Steps | Get Help

Causes of Major Depressive Disorder

Theoretically, depression is caused by a chemical imbalance, but definitive proof has yet to surface. And while scans show physical cranial differences between those with and without depression, these differences do not tell us exactly why the changes are present. Therefore, it’s not always possible to determine the exact cause of a patient’s major depressive disorder. The following, however, are a few potential explanations for development of the disease:

1. It runs in the family. If your parents or siblings suffer from major depression, your risk of developing it is two or three times greater than the average person—and that’s not because your family “brings you down.” A family history of depression is like a family history of alcoholism or heart disease: It’s a warning to take care of yourself and to avoid physical and emotional triggers.

Even though depression is clearly biological and genetic, scientists don’t believe there’s a “depression gene” per se; it’s more likely that several genes contribute to depression and what you inherit is only a predisposition. If you are loved and encouraged in childhood, and life treats you well, you may be fine. If, on the other hand, there are troubling life events compounding a genetic disposition—for example, a parent dies when you’re young—then you would be at a greater risk of suffering major depressive episodes.

2. Temperament. It’s possible that your major depressive disorder stems from something called negative affectivity (NA), which pertains to how you experience negative emotions and poor self-perception. Those with high levels of NA appear more likely to develop depressive episodes in response to stressful life events, while those with low levels of NA may be generally more content regardless of external stimuli

3. Environment. We’ve kind of mentioned this already, but your environment can play a part in developing major depressive disorder. Traumatic events and situations, depending on the individual, have been known to incite major depressive episodes. A childhood trauma, the loss of a loved one, or a troublesome work atmosphere are just a few examples of stressors that may lead to depression.

4. Course Modifiers. Simply put, a course modifier is something that alters the course of a disease. According to the DSM-5, “essentially all major non-mood disorders increase the risk of an individual developing depression.” Anxiety, substance use and borderline personality disorders are potential course modifiers that can lead to major depressive symptoms, as can chronic or debilitating medical issues.

NOTE: It’s possible that your medical doctor might not be able to distinguish between your depression being a symptom of a course modifier or it being a separate condition altogether—and making that determination may not be ultimately significant. In either case, it’s crucial that you tell your doctor about your depressed mood or feelings, even if you think they’re simply the natural result of another issue. Medical issues are often more difficult to treat than depression, and any sort of relief you experience from depression will only make your other issues more endurable.

Jump to: Portraits | Definition | Diagnosis, Signs and Symptoms | Causes | Treatment | Action Steps | Get Help



If you listen to popular media, you probably believe every other person is taking antidepressants and most likely SSRIs like Prozac, Zoloft, Paxil, and Celexa. The number, however, is one in six. Now, depending on what you read or watch, you might also come away believing that antidepressants defeat depression the way antibiotics kill bacteria; or that they’re placebos that do nothing but enrich the pharmaceutical companies; or that they’ll first destroy your sex life then drive you to suicide. Of course, none of this is true either.

It’s true that antidepressants have made money for big pharma, some users do experience sexual side effects, and some people can become suicidal. But they also work miracles: when they work, you know it. One day (usually a couple of weeks after treatment starts) you feel significantly better and the improvement lasts, at least as long as you’re taking the medication.

Selective Serotonin Reuptake Inhibitors (SSRIs) work on brain chemicals called neurotransmitters, or more specifically, serotonin. These chemicals are involved in regulating mood. New studies are published all the time on their effectiveness—so if you decide to take antidepressants, it’s a good idea to keep abreast of new developments, and/or discuss them with your doctor. What is known, however, is that…

  • The drugs are more helpful to some than others.
  • Side effects can be uncomfortable and (in rare cases) dangerous and should be reported to your physician.
  • They are not addictive in the usual sense—you won’t experience cravings or the need to take larger and larger doses. But they may stop working for some people, especially if one takes the medication, stops, and then starts again.

Common side effects of antidepressants include dizziness, anxiety, abdominal pain or discomfort, headaches, dry mouth, dry eyes, a racing heart, difficulty maintaining erection or achieving orgasm, and decreased libido. These, however, do not typically outweigh the benefits of the medication. And if they persist or worsen over time, a simple discussion with your doctor may result in an easy, effective solution.

There are many other drugs used to treat depression, including MAOIs and Tricyclic antidepressants. They all work on different neurotransmitters, and may or may not be more effective in particular cases; therefore, you should not assume that because one doesn’t work, none of them will. Before starting your antidepressant, discuss with your doctor what to expect, how soon to expect it, what the side effects might be, whether there are foods or other substances you should avoid, how the drug will interact with any other medications you might be taking, and whether the drug might affect any medical conditions you have.

Your primary care physician can prescribe antidepressants, but you should schedule at least a few visits with a psychiatrist if possible, as psychiatrists generally have more experience with such drugs and generally have a better idea of the efficacy of each one for particular symptoms.

Counseling/Talk Therapy

Counseling can be extremely helpful in the treatment of depression, as well as many other mood disorders. One popular and effective method of counseling is known as cognitive behavioral therapy (CBT).

How Does It Work?
In the 4th century B.C., a philosopher by the name of Epictetus stated, “Men are disturbed not by things, but by the views which they take of them.” Cognitive therapy closely parallels this idea (as well as Buddhist and Taoist ideas) that emotions are a product of one’s thinking.

In the 1950s, some mental health professionals were becoming disenchanted with the Freudian-style of counseling, known as psychoanalysis. The criticism was that with psychoanalysis clients would come to understand why they had problems, but the process of providing a timely cure for common life problems was lacking. CBT is a holistic approach to counseling, which teaches that a person’s feelings (and actions) are not a consequence of external events, but instead stem from of an individual’s internal beliefs and thoughts. A simple equation for understanding this relationship is A+B=C.

  • A = The Activating Event
  • B = Thoughts or Beliefs
  • C = Emotional and Behavioral Consequence

Example of How Thoughts Dictate Our Mood:
Ken is stuck waiting in line at the Department of Motor Vehicles (DMV) for over an hour. When it’s finally his turn at the front desk the DMV employee informs him that because he lacks a necessary form, he won’t be able to register his new car. What’s more is Ken called the DMV ahead of his arrival, asked a representative what forms he would need, and brought all the materials as instructed. Since he was incorrectly directed by a DMV representative, he will have to return at a later time—with more documentation—and begin the process again. Irate, Ken storms out of the DMV. Ken believes that he is angry because he had to wait “much too long” at the DMV, and because he was “lied to” by a DMV representative. He also has a few other thoughts, some that he barely notices he’s having, which include:

  • “Crap like this always happens to me.”
  • “I can never catch a break.”
  • “Bad luck is a curse in my family.”
  • “I’m such a fool for not just bringing every form I had; I should’ve known.”
  • “My life sucks.”

Consequently, Ken feels rotten for the rest of the day. According to CBT, Ken isn’t upset because of the event at the DMV (A). Instead, only Ken’s thoughts and beliefs (B) have the power to affect his mood and emotional consequence (C). Now, let’s suppose on the same day another person, “Dan,” had the same DMV experience, but different thoughts. How might the emotional response differ?

Dan is stuck waiting in line at the Department of Motor Vehicles (DMV) for over an hour. When it’s finally his turn at the front desk the DMV employee informs him that, because he lacks a necessary form, he won’t be able to register his new car. What’s more is Dan called the DMV ahead of his arrival, asked a representative what forms he would need, and brought all the materials as instructed. Since he was incorrectly directed by a DMV representative, he will have to return at a later time—with more documentation—and begin the process again (does this story sound familiar?). Upon hearing this unfortunate news, Dan chuckles to himself, thanks the representative at the counter, says, “See again you in about an hour!” and calmly walks out of the DMV. How did Dan keep his cool? Instead of the negative self-talk of Ken, Dan’s thoughts were very different, and included:

  • “Oh well, these things happen.”
  • “Everyone knows going to the DMV can be an inefficient process, all you can do is laugh it off.”
  • “This wasn’t ideal, but it doesn’t need to ruin my mood or my day.”
  • “I’ll go get the paperwork and at least I’ll get this completely taken care of today.”
  • “Hey, I have a new car! Nothing can ruin my mood today!”

Dan can even think positive things that put his DMV experience into perspective: “I have a family and two healthy kids. And it’s a beautiful day.” Unlike Ken, Dan is still feeling good. The mistake made by the DMV representative and the long waits don’t ruin his mood because his thoughts about the event are more positive and truer. Ken’s thoughts, however, were downright false, including, “My family is cursed,” and, “I can never catch a break.” But boy, did they feel true for him at the time.

When one is struggling with depression, often his or her thought patterns reflect more closely the thoughts of Ken, as opposed to Dan. However, through counseling one can learn to better detect and change his or her negative thinking patterns. This change can have a huge, fast, and positive impact on one’s depressed mood.

Jump to: Portraits | Definition | Diagnosis, Signs and Symptoms | Causes | Treatment | Action Steps | Get Help

Action Steps

1. Get creative.
Creative activity is very effective in alleviating depression. If there’s a particular creative activity you love—drawing, playing piano, cooking, crafting—embrace it. Many therapists use the arts in their treatment, particularly art forms that result in images that can be discussed. But even decorating a cake or picking up an instrument you used to play can engage your attention, and jog you out of negative thoughts. Creative work channels your imagination in positive ways and connects you to your deepest self.

2. Listen to music.
We all choose music to suit our mood, but any kind of music can be a mood-changer and even serve as a form of therapy. The eminent neurologist Oliver Sacks writes, “Music can lift us out of depression or move us to tears—it is a remedy, a tonic, orange juice for the ear. But for many of my neurological patients, music is even more—it can provide access, even when no medication can, to movement, to speech, to life. For them, music is not a luxury, but a necessity.” Music interrupts the rhythm of your thoughts; it literally tunes your mind and body to its own beat, and if you’re in a rut of negative thinking, it can be liberating.

3. Meditate.
A study at John Hopkins University found that mindfulness meditation resulted in a 10 to 20 percent reduction in symptoms of depression among the meditating subjects, as compared to a control group. Meditation works by teaching the mind to focus on something neutral, like one’s breathing, and to become aware of and then let go of thoughts. The techniques learned can be used to turn away from negative thoughts even when you’re not meditating. Meditation may also work on a more profound level, relaxing or centering you. It’s something you can do anywhere, and it demands very little time.

4. Practice gratitude.
Making a list of what you are grateful reminds you that a lot of good things in life get taken for granted because our brains evolved in such a way that the novel and the dangerous always make the biggest splash. That’s fine if you’re traveling, just arrived at college, or are navigating a jungle full of predators. But for most of us, the familiar day-to-day aspects of our life are just as, or more important, than the new and scary. The more primitive part of your brain doesn’t know that, though, so you have to remind it.

5. Take care of your physical needs.
There’s a very strong connection between the mind and the body. When you exercise, you not only relieve stress, improve your metabolism, boost your immune system and burn fat, but you also release mood-boosting endorphins, which can help you cultivate a more positive outlook on life.

Also, it’s important to understand that insomnia and depression often go hand in hand. Doctors used to think of the insomnia of depression as secondary—something that would clear up when the depression did. But widely reported new research at Ryerson University in Toronto, suggests that insomnia often predates the depression and, in fact, can trigger it.

Scientists found that insomnia (over a month of serious sleep problems) doubles a person’s chance of developing depression. Curing insomnia makes curing depression easier. Sleep therapists suggest reserving your bed for sleep (no eating, reading, or watching TV in bed), going to bed at the same time every night, keeping the bedroom quiet and dark, and avoiding alcohol and caffeine in the hours before bed.

The rules are simple, yet not always followed: Eat well (nutritiously and appropriate to your body’s type and needs), sleep well, and exercise regularly. Without addressing your physical needs, addressing your psychological needs is exceedingly difficult.

6. Take care of something or someone.
Do you like dogs, cats, hamsters? If you’re not sure, wander down to the nearest shelter and hold some of the cats, pet some of the dogs. See if you feel drawn to one. Many depressed individuals have found that the small amount of care an animal requires is just within what they can do and it has some extraordinary mental health benefits. Animals are not judgmental. They’ll be delighted if you stay home all day. They don’t care if you bathed this morning. If you’re feeling especially sad, they’ll do their best to comfort you without telling you to snap out of it and get a life. Animals are happy just to hang out and share the life you already have.

7. Socialize.
No one expects someone in the grip of terrible darkness to be the life of the party, or be the one to go read to an elderly shut-in. But take those baby steps, if you can. You can, right? You can make a phone call. You can walk to the grocery store and remember to smile at the cashier.
If your depression is milder, or if you are recovering and don’t want to relapse, scheduling lunches and dinners with friends, joining groups that meet regularly, and getting involved in a cause you feel passionate about will help you far more than you may realize. If you love children, volunteer at the local library. If you care about the environment, become an activist. Get involved at your local church food drive or community soup kitchen. The strength of your social networks has a direct correlation to strength of your mood. The more activities that have meaning and value beyond earning a living, shopping, or chasing transient pleasures, the more resilience to depression you will develop.

8. Be honest with yourself and get help:
Professional help from a skilled and genuinely caring counselor or coach is available, yet many suffering from depression are often too ashamed of their negative feelings to actually seek one out. What you need to realize is that millions of people have experienced exactly what you’re going through right now and have learned through counseling and coaching how to live a fulfilling and joyful life—and you are no different. So don’t wait another second—say yes to treatment and be on your way to discovering happiness again.

Jump to: Portraits | Definition | Diagnosis, Signs and Symptoms | Causes | Treatment | Action Steps | Get Help

Why Do We Care So Much? Get Help Today

Why do we want to help? It’s simple, really. Much of the world’s woes are exacerbated (if not caused) by the vicious nature of mood disorders, and we believe that these issues can be greatly lessened (if not eradicated) through the transformative processes of counseling and coaching.

Literally, we want to help save the world.
Perhaps you’re like many others, and have tried keeping the problem to yourself. By this point, you’ve probably discovered that anxious secrecy and woeful solitude don’t work. Or, perhaps you’ve never tried counseling, so you’re not convinced on how effective it would be for you. Well, you could take others’ word for it, or you could give it a shot and experience for yourself how you can thrive, and we can help. Click here to see a counselor or coach this week, if not within 24 hours, at a location near you. Or, if you’d prefer to try online counseling, click here. Whichever you choose, we look forward to meeting you and joining you on your mental health journey.