Introduction

It is normal and part of being human to feel low or sad at times – it is normal to feel sad or down in response to an upsetting experience, a break-up, illness, problems with family or friends or for no reason at all. Usually when this happens, a person can go on with their day and keep up with activities of daily living. This type of sadness and down mood doesn’t last long and usually resolves itself when the situation improves or time passes.

Major Depressive Disorder (MDD) and other mood disorders are very different from the type of sadness and down mood that people feel from time to time.  MDD is a significant change in mood from their usual mood that lasts at least two weeks and causes a person to feel depressed nearly all day, every day or to lose interest/pleasure in all activities. With a major depressive disorder, the episode of depressed mood or loss of interest in activities is always associated with a significant level of distress and impairment in school/work, relationships and self-care.

Impact
The impact of depression extends beyond the person struggling with the illness. Depression can have a marked impact on relationships with family members, friends and on a person’s ability to connect with the community around them (such as with teachers or coaches). Depression in the teen and young adult years can result in repeated absences from school, poor school performance and impaired ability to progress toward independence.

Prevalence

Major depression is a common illness affecting teens in the U.S. In 2014, 2.8 million people age 12 – 17 years old had at least one major depressive episode in the past year (NIH). According to the National College Health Assessment survey, 14.5% of college students reported having been diagnosed with or treated for depression in the previous year. Women are 70% more likely than men to develop depression (NIH).

Half of the people who have an episode of major depression will only experience one episode in their life. However, 50% of people who have a depressive episode will experience subsequent depressive episodes. Although episodes may resolve on their own within a few months without treatment, untreated depression can persist for up to several years (NAMI).

Since symptoms often first develop during the teenage and college years, it is very important to look out for signs of depression during this time.

Signs and Symptoms

People with depressive illness do not all experience the same symptoms. Problems vary in intensity and consistency but are present for at least two weeks.

Change in Mood and Thoughts

• Persistently low, down, depressed mood – feeling sad, empty and hopeless
• Low self-esteem – feeling worthless
• Feeling guilty and unworthy
• Thoughts about death and suicide
• Irritability – teens tend to exhibit irritability more than sadness
• Psychosis –hallucinations (hearing or seeing things that are not there) or delusions (believing things that are not based in reality). Of people with major depression, 5-15% will experience psychotic symptoms as part of their illness

Change in Behaviors

• Restlessness
• Persistent loss of interest in activities that used to be pleasurable or interesting, including sex
• Loss of interest in how they look, poor hygiene
• Difficulty concentrating, remembering details and making decisions
• Insomnia, early morning wakefulness or excessive sleeping
• No appetite or overeating

Physical symptoms

• They may look very sad or empty or appear distracted
• Loss of weight
• They may complain about multiple physical symptoms that are not due to other medical issues – such as headaches, digestive problems, muscle aches and pains.

The American Journal of Psychiatry

Types of depressive disorders

Major Depressive Disorder (MDD)
MDD is a period of sadness or apathy along with several other depressive symptoms that last all day, nearly every day for at least two consecutive weeks. The symptoms are severe enough to interfere with daily activities (school/work, study, eating, enjoying friends and family).

• In some cases, when a person has suffered a significant loss (death of a loved one, serious medical illness, loss from a natural disaster) it can look like they have MDD. More often than not, the symptoms of depression related to a significant loss resolve over time without the need for intervention.
• Major depressive disorder with a seasonal pattern – known as “seasonal affective disorder” or SAD. This is when there is a seasonal pattern to the onset of depressive symptoms or a seasonal pattern to the disappearance of symptoms. For example, a person’s depressive symptoms lift in the spring and return in winter.

Persistent depressive disorder
Previously called dysthymia, persistent depressive disorder is characterized by depressed mood that lasts for at least two years. The severity of symptoms is typically less than for major depression. Persistent depressive disorder affects approximately 1.5% of the adult population in the United States. 

Premenstrual Dysphoric Disorder (PMDD)
The important features of PMDD are mood changes (irritability, unhappiness, labile mood, anxiety) that occur repeatedly in the premenstrual phase of the cycle (just before getting a period – menses) and go away once menses has started. In addition to mood changes, other physical and behavioral symptoms may be present – in order to meet the criteria for PMDD, the symptoms a person experiences must have a negative effect on school or social functioning and must be present in most of the menstrual cycles in the past year. PMDD is different from other depressive disorders because there is a symptom-free period of time (no mood changes or other symptoms) in the weeks following the onset of a period.

Risk of Suicide

People who struggle with depressive disorders are at increased risk of having suicidal thoughts or impulses for suicide. Sadly, an estimated 2-15% of people who have major depression die by suicide.

When a person is struggling with a depressive disorder, it is very important to look for signs and symptoms that might suggest that they are at risk for suicide. Asking someone about suicidal thoughts does not plant the idea in their head. More often than not, someone who is thinking about suicide will give some warning of their intentions to a friend, family member, teacher or health care provider. All suicide threats, gestures and attempts must be taken very seriously and brought to the attention of professionals.

Here are some signs that a person may be at risk for suicide:

• Chronic hopelessness
• Intense or uncontrolled anger or seeking revenge
• Acting recklessly or engaging in risky activities, seemingly impulsively or without thinking
• Feeling trapped or like there’s no way out
• Increased alcohol or drug use
• Withdrawing from friends, family, teachers – wanting to be left alone
• Hanging out with a new group of friends who might have a reputation for substance use
• Anxiety, agitation, inability to sleep or sleeping all the time
• Dramatic mood changes
• Expressing no reason for living or no sense of purpose in life
• Talking about wanting to die
• Seeking access to potentially lethal means such as guns, knives, high windows in a dorm
• Prior suicide attempts

If you are concerned that you or someone else may be suicidal, take the situation very seriously and get yourself or them connected to help as soon as possible. Text “START” to 741-741 or Call 1-800-273-TALK (8255) or call 911 or go to the nearest emergency room if you feel the person is in immediate danger of hurting themselves.

Causes

There is no single cause of depression. Rather, it appears that the illness develops due to a combination of genetic, biological and psychological factors and life experiences. Depression can occur in a person with no family history of depression; people with a family member who struggles with a major depressive disorder do have a higher risk for depression. Depression in early teen years might be connected to external stressors (such as abuse, the death of a loved one or a traumatic event), and teens with behavior problems or anxiety are more likely to become depressed. In older teens and young adults, depression can develop without apparent connection to external events.

What else could it be?
Depressive symptoms are associated with a number of other medical and psychiatric conditions, and depressive disorders can co-occur with other illnesses. A comprehensive medical and psychiatric assessment is an important step in accurately diagnosing the disorder and developing a treatment plan. Part of the process of correctly diagnosing a major depressive disorder involves ruling out other reasons for depressive symptoms such as medical illness (thyroid dysfunction, Lyme disease, etc.), substance use or medications. Also, many other psychiatric illnesses can have depressive symptoms as part of the underlying condition or can occur at the same time as a major depression.

Treatment

When it is appropriate, treatment for a mild major depressive disorder (first episode, without suicidal thoughts or psychosis) would start out with psychotherapy. For more serious episodes, or recurrent depression, a combination of psychotherapy and medication is an effective approach. At the beginning of any treatment, a comprehensive medical and psychiatric history and examination should be obtained.

Psychotherapy
Over time, therapy can reduce the intensity and frequency of emotional pain and other symptoms, alter negative patterns of thinking, bolster self-confidence and lead to an overall improvement in well-being. There are many different types of psychotherapy that are effective in the treatment of a major depressive disorder. Psychotherapy can also be used with families, couples or groups.

Types of therapy that are effective in teens and young adults include:

• Cognitive behavioral therapy (CBT):
  • This type of treatment will help improve mood by helping a person understand how their negative thought patterns can affect their feelings, mood and behavior. Over time, a person will learn to recognize the negative patterns and develop strategies to replace them with thoughts and behaviors that lead to more positive and healthy outcomes.
• Psychodynamic psychotherapy:
  • Psychodynamic therapy works to uncover negative patterns rooted in past experiences that might contribute to current painful feelings and problematic behavior. Once these patterns are understood, psychodynamic therapy helps to resolve them. Over time this can lead to improved mood and greater insight into current feelings and behavior.
• Interpersonal therapy:
  • The focus of interpersonal therapy is the relationships a person has with others. The goal of this type of therapy is to improve a person’s ability to build positive interpersonal connections. Past relationships are explored in order to recognize negative patterns. The goal of interpersonal therapy is to help a person struggling with a mood disorder develop effective strategies for understanding and interacting more positively with others.
• Dialectical behavior therapy (DBT):
  • Dialectical behavior therapy (DBT) is similar to CBT but DBT includes accepting uncomfortable thoughts, feelings and behaviors in addition to challenging them. DBT focuses on helping a person develop new coping skills to help improve problematic thoughts and behaviors. DBT often includes homework in between sessions to help a person struggling with depression practice the new skills they are developing.

Medication
Medication can help alleviate symptoms associated with major depressive disorder and enhance functioning in daily life. Medication for depression works by altering the levels of neurotransmitters in the brain. When prescribed by a mental health professional and monitored closely, anti-depressant medications can be a safe and effective way to treat the symptoms of major depression. The onset of symptom relief can take several weeks and sometimes a person may need to try more than one anti-depressant before the desired improvement of symptoms is achieved. Though anti-depressants are not considered addictive, stopping them abruptly without a doctor’s supervision can cause withdrawal-like symptoms including feeling uneasy, nausea and flu-like symptoms.

Types of antidepressants include:

• Selective-serotonin reuptake inhibitors (SSRIs): Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram), and Lexapro (escitalopram)
• Serotonin-norepinephrine reuptake inhibitors (SNRIs): Effexor (venlafaxine), Cymbalta (duloxetine) and Pristiq (desvenlafaxine)
• Atypical anti-depressants: Wellbutrin (bupropion), Trintellix (vortioxetine), Desyrel (trazodone) and Remeron (mirtazapine)
• Tricyclic anti-depressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are older types of anti-depressant and are less commonly used because of more significant side effects
• When psychosis is present or sometimes when depression is severe and does not respond fully to standard anti-depressants, antipsychotic medications will often be added – these are known as atypical anti-psychotics and include Clozaril (clozapine), Risperdal (risperidone), Seroquel (quetiapine), Zyprexa (olanzapine), Geodon (ziprasidone), Abilify (aripiprazole) and Latuda (lurasidone)

Electroconvulsive therapy (ECT)
ECT is a treatment that passes electrical currents through the brain while a person is sedated with anesthesia. ECT can offer nearly immediate relief of severe depression for many people when other treatments have failed to work, when they can’t take medication for health reasons or they are at imminent or high risk for suicide. Side effects can include headache and memory loss, but these are usually temporary.

Lifestyle interventions
Though modifications in a person’s lifestyle will not treat a depressive disorder, there are relatively simple things that can be done to minimize the symptoms of depression. The effectiveness of exercise in reducing depressive symptoms is well established. Regular exercise, no matter how rigorous or long in duration, is a simple and effective way to help depression and keep a person who is struggling with depression engaged in their own recovery.