Let's Talk About the Types of Depression
People often talk about depression like it's a single diagnosis, but did you know there are all kinds of types? Learning what makes them different can help you get the best diagnosis and treatment, so you can feel better faster.by Meirav Devash Wellness Writer
There are nearly as many types of depression as there are flavors of ice cream. That’s why I, a person with depression who really likes ice cream, imagine it as a somber little sundae. Does that seem flip? Hear me out: Mine has two scoops of persistent depression, a heaping spoonful of major depression, a sprinkle of generalized anxiety, and (chef’s kiss!) a melancholy cherry on top. Everyone’s depression sundae looks and tastes different, but they’re all quite unappetizing, nobody remembers ordering theirs, and everyone wants to send them back. Here, we’ll go over the different categories of clinical depression and how they differ. Figuring out the specific makeup of your depression will help you grasp what’s happening and give you a better way to talk about your experience.
Our Pro Panel
We asked some of the nation's top depression experts to bring you the most up-to-date information possible.
Charles B. Nemeroff, M.D., Ph.D.
Chief Medical Officer of the Anxiety and Depression Association of America, Professor and Chair of Psychiatry at Mulva Clinic for the Neurosciences
Dell Medical School, The University of Texas
Jennifer L. Payne, M.D.
Director of the Women's Mood Disorders Center and Associate Professor of Psychiatry
Johns Hopkins School of Medicine
Carol A. Bernstein, M.D.
Psychiatrist, Vice Chair for Faculty Development and Well-Being in the Departments of Psychiatry and Obstetrics and Gynecology
Montefiore Medical Center/Albert Einstein College of Medicine
The Bronx, NY
Manic depression is a now-outdated name for bipolar disorder, a mental disorder characterized by wide mood swings that go from vertiginous heights (a.k.a. mania or hypomania, a milder form) to deep lows (a.k.a. depression). During a manic episode, you’re teeming with energy, verging on snappy and irritable. You might find yourself making grandiose plans, not sleeping much, and acting recklessly, i.e. spending too much cash or sleeping with your ex when you said you were going no-contact. In severe cases, you may experience psychotic symptoms like delusions and hallucinations. During a depressive episode, your mood freefalls and you get no pleasure out of your usual happy places. You feel guilty, worthless, and may even think about self-harm or suicide. In the case of suicidal thoughts, call the National Suicide Prevention Hotline at 1-800-273-8255.
First, congratulate yourself for stepping up to the plate. It’s easy to ghost a friend when they stop being fun, especially if they start lashing out. If you’ve noticed that they haven’t seemed like themselves lately, say that, and ask how they’re doing. Then listen. Don’t try to fix their issue. Just listen to their feelings. Don’t be afraid to ask them (not in an accusatory way) if they’ve thought about hurting themselves. Unless you yourself are a psychotherapist, the next step is getting them some professional help. Luckily, a little moral support goes a long way here. Remember, in a depressed state, even basic tasks can seem Herculean. Instead of saying, “You should really talk to a therapist,” which can come off sounding judgy and a little bit bossy, why not help them make an appointment? You don’t have to go full-on caretaker—just ask what their insurance provider and plan is, Google local therapists, and call reception to find out if the doc takes new patients and your friend’s insurance plan. You can present them with a list of available options and offer to schedule their first appointment and even drive them there.
Depression is so common that it’s easy to forget just how devastating this psychiatric illness can be when left untreated. Across the globe, depression affects more than 264 million people of all ages. Here in the U.S., 17.7 million people (that’s 7.2%) experience Major Depressive Disorder, the most common type, each year.
Yes. In fact, clinical depression is one of the world’s leading causes of disability, according to the World Health Organization. In the U.S., around 6% of people receiving Social Security disability benefits are unable to work due to a mood disorder like depression. Social Security Disability Insurance Benefits (SSDI) & Supplemental Security Income (SSI) are programs set up to assist people who are unable to work with monthly income and health insurance. Claims are usually processed and investigated through your local Social Security office.
What Do I Need to Know About Depression?
Let’s summarize the basics: Depression is an often-debilitating mental disorder that’s more than just sadness (although that’s part of it). Mostly, depression feels hopeless. Every day, you feel like you’re slogging through knee-deep molasses, like a night of restful sleep is a fantasy, like your mental fatigue will never end, like you’ll never be able to rejoin the world or feel the tiniest bit of pleasure from anything again. The symptoms sap your energy and joie de vivre. After a while, it’s no wonder that many people’s work performance and personal lives start to implode.
Like it or not, depression isn’t going to fix itself. It’s essential that you get help or encourage your depressed friend or loved one to do so. Depression is a cyclical disorder, so it won’t simply go away. More than half the people who have one depressive episode experience a recurrence. If it happens twice, there’s an 80% chance that there will be a third. Treatment can help you feel better faster, as well as attune you to the patterns of your depression so you can (hopefully) anticipate episodes and create action plans.
What Are the Types of Depression?
Depression isn’t a one-size-fits-all diagnosis. There are several varieties of depression, all with different onsets, symptoms, and treatments. Here are the most common depression types.
Major Depressive Disorder (MDD)
When people hear the word “depression,” this is what they’re thinking of—usually personified by some lady in an antidepressant commercial who is too sad to look out the kitchen window and doesn’t pet the family dog anymore. MDD, another term for clinical depression, goes beyond typical periods of sadness that eventually pass. For nearly 18 million Americans who deal with clinical depression each year, this is what things look like:
Low mood and zero capacity for joy are the main symptoms of depression. (See? That’s why the lady in the commercial doesn’t pet the dog.)
This gloomy mood lasts at least two weeks but usually longer, from months to years, and is severe enough to disrupt your everyday life.
Mornings start with a suffocating sense of dread. You’re physically drained, you feel hollow, and you’ve started stuffing your pockets with tissues since you’re likely to burst into tears at any moment.
You could have a change in appetite or noticeable weight gain or loss. Maybe you’re overeating because you just want to fill that empty feeling with potato chips, or maybe you’re skipping meals because your desire to eat has vanished into thin air.
Clinical depression also comes with all kinds of sleep problems. You might lie awake with racing thoughts or finally catch some Zs, only to wake up every few hours. Maybe you’re so tired you can barely peel yourself out of bed or keep your eyelids open past lunchtime.
If you’re thinking and moving in slow motion, that’s called psychomotor retardation; if you’re so restless you’re biting your nails or picking your skin, that could be psychomotor agitation (they’re both symptoms).
You can’t concentrate on anything, and making decisions feels impossible.
You feel guilty for no good reason, like you’re worthless, and maybe even like the world would be better off without you. (Not true, even if it feels hopelessly so. Depression subverts the logic of your brain, which is why you need to seek help right away. If you’re having suicidal thoughts, please contact the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).)
Docs usually treat MDD with a combination of psychotherapy and antidepressants, usually SSRIs (selective serotonin reuptake inhibitors) like Prozac (fluoxetine) and Zoloft (sertraline) and SNRIs (serotonin and norepinephrine reuptake inhibitors) like Effexor (venlafaxine) and Cymbalta (duloxetine). In some cases, your doc might recommend other drugs—MAOIs (monoamine oxidase inhibitors) like Marplan (isocarboxazid) or Nardil (phenelzine), or TCAs (tricyclic antidepressants) like Elavil (amitriptyline) and Norpramin (desipramine). For severe depression, they may suggest non-drug options like ECT (electroconvulsive therapy) or rTMS (repetitive transcranial magnetic stimulation).
Persistent Depressive Disorder (PDD)
This is a chronic form of depression formerly known as dysthymia. You may still hear therapists and doctors call it by that name, since that’s what it was known as until 2013, when the DSM-5, the official guidebook of mental health conditions, smushed “dysthymia” (mild depression not as severe as MDD) and “chronic major depressive disorder” (MDD lasting two years or longer) into one condition, PDD. Treatment is similar to what docs use for MDD. Read above!
Most people with PDD feel like they’ve always been kinda depressed and have a pretty low baseline of happiness (think Eeyore or that ’90s MTV cartoon, Daria), but there are also PDD’ers who are severely chronically depressed for six or seven years. Some doctors feel like patients who experience both severe and chronic depression are not adequately represented by this diagnosis. If you've had PDD for years and experience a major depressive episode, clinicians call that double depression.
Many people think that if you’re able to get up in the morning, slap on some clothes, and get through your day, you can’t be that depressed. That’s where we got the notion of “high-functioning depression.” (Online searches for the term started popping up in 2004 and peaked in 2016, according to Google Trends.) Just a heads’ up, though: High-functioning depression isn’t a clinical term and you won’t find it in the DSM-5, along with “smiling depression” and “hidden depression.” They’re all essentially pop-psychology names for Persistent Depressive Disorder.
People with depression, however, are drawn to this unofficial diagnosis because it sweeps the social stigma attached to being mentally ill under the rug. Being a high-functioning anything doesn’t sound so bad, or like a burden, or like something so serious it requires medical intervention. The danger of unofficial terms like this one is that people with less severe symptoms of depression are less likely to seek out help. You may feel guilty about feeling bad or not think you’re “depressed enough” to need help. You might not see that life can get better. Plus, even if you put on a happy face, being in a sort-of-depressed state for an extended period puts you at risk of developing more severe MDD symptoms.
Though it’s not listed under Depressive Disorders in the DSM-5—bipolar has its own section—there are depressive elements to this mental condition. Bipolar disorder causes extreme mood swings from emotional highs (mania or hypomania) and lows (depression). Everyone has ups and downs, but these mood swings affect functioning in your day-to-day life. When your mood goes high, you’re the opposite of depressed— you might feel euphoric, chatty and full of grandiose ideas, super-energetic, or unusually agitated and irritable. But when your mood goes low, it comes on like a major depressive episode. Symptoms include:
Feeling sad and hopeless
Losing interest in nearly everything
Feeling lethargic and exhausted
Eating too much or too little
Feeling worthless or excessively guilty
Scattered thinking and indecisiveness
Having thoughts of suicide
Docs usually treat bipolar disorder with a combination of therapy and medication, usually mood stabilizers like Lithobid (lithium) and Depakene (valproic acid) and atypical antipsychotics like Risperdal (risperidone) or Seroquel (quetiapine).
Seasonal Affective Disorder (SAD)
If you notice that when the clocks “fall back” each year, your mood also takes a dive, you may have seasonal depression. SAD is the only one of these depression acronyms people actually use in real life, though the clinical name for it in the DSM-5 is “depression with seasonal pattern.” Some details:
Women get SAD four times more often than men.
The further away you live from the equator, the more likely you are to get it. (Sorry, Norway.)
Seasonal symptoms start and end around the same times every year, usually in the long, dark days of winter, although some people do get despondent in summer.
If you have the winter version, you spend the season hibernating or acting grouchy and emo. Scientists believe winter SAD is due to the lack of sunlight disrupting your circadian rhythms (the “internal clock” that regulates your sleep-wake cycle). Some people experience SAD in reverse—summer SAD. The theory here is extreme sunlight and heat in the summer months jacks up their circadian rhythms. Research shows people with SAD have lower serotonin levels and may produce too much melatonin, a hormone that regulates sleep.
When you’ve got the winter version of SAD, you’re most likely:
Super low energy
Drinking too much
Having crazy carb cravings
Sleeping too much
Being a social hermit
When you’ve got the summer version of SAD, you’re most likely:
Not very hungry
Not getting enough sleep
Agitated and restless
Feeling more anxiety
Irritable and even violent
Winter SAD can be treated with SSRIs (selective serotonin reuptake inhibitors) and bupropion, another type of antidepressant; light therapy; CBT (cognitive behavioral therapy) and realigning your sleep cycle with timed doses of over-the-counter melatonin supplements in the early evening. For summer SAD, antidepressants and CBT are similarly effective. Also useful? Avoiding bright sunlight and excessive heat and humidity by staying in the AC and keeping the shades drawn.
Premenstrual Dysphoric Disorder (PMDD)
Only people who menstruate get this disorder, where you feel like yourself for most of the month, until depression symptoms start about one week before your period and end just after your period. Each month, you transform into a PMS version of The Hulk where instead of super strength, you exhibit super sadness, along with super crankiness, high anxiety, crying jags, fatigue, food cravings, sore boobs, and bloating. The symptoms are way more severe than typical PMS. They make it impossible for you to reliably work, your friendships and relationships suffer, and you may even have thoughts of suicide.
One problem with diagnosing PMDD is that it can look a lot like premenstrual exacerbation, which is when your period makes the symptoms of another illness worse (like, say, if you already have clinical depression). The difference is that with PMDD, you’re only depressed during a certain time of the month called the luteal phase of your cycle. To make sure you’re treating the right disorder, doctors will ask you to keep a record of your symptoms—in PMDD, they should appear the week before your period, and start to recede a few days after your period starts. They disappear after your period does, and you’re back to your usual self.
Docs usually treat the disorder with SSRIs—studies show that serotonin-targeting drugs work better for PMDD than other types of antidepressants—plus hormone therapy like Yaz (drospirenone and ethinyl estradiol) or topical or subcutaneous estrogen.
Peripartum Depression (PPD)
Childbirth-related depression usually happens postpartum, but sometimes symptoms start during pregnancy and sometimes when the baby is several months old, which is why they all fall under the “depression with peripartum onset” umbrella. Thanks to an unpredictable cocktail of pregnancy hormones, new mothers often feel like they’re on a roller coaster of emotions. Just add a lack of sleep, post-birth pain and discomfort, and an endless soundtrack of pathetic wails emanating from your infant, and what could go wrong?
A few things, as it turns out. As many as 50% to 75% percent of new mothers get the “baby blues” after delivery (crying, anxiety, sadness), which usually wanes in about two weeks. However, up to 15% of new moms develop PPD, which means that along with the usual symptoms of clinical depression, they may slip into apathy at a time when everyone expects them to be smitten with their baby. They might have a hard time bonding with the tiny squirmy being at the center of their world, or even contemplate hurting themselves or the baby. In some cases, docs treat postpartum depression with an IV infusion of Zulresso (brexanolone), a version of the body’s own neurosteroid called allopregnanolone.
In rare cases (only 0.1-0.2% of mothers, usually associated with concurrent bipolar disorder or schizoaffective disorder), they experience postpartum psychosis, which includes delusions (false beliefs, usually centered around the baby) and hallucinations (false perceptions, like hearing voices that aren’t there). Most new moms having a psychotic episode aren’t aware of it, so it’s important to keep an eye out for these symptoms. Consider them a psychiatric emergency and find help ASAP before it escalates to harming themselves or the baby. Such violence is rare, but research estimates that untreated postpartum psychosis carries a 5% percent risk of suicide and a 4% risk of infanticide.
It’s probably becoming clear that, for women, dramatic hormonal changes are a big trigger for clinical depression. Along with menstruation and childbirth, the years leading up to menopause, called perimenopause, is another hormonal danger zone.
This is due to inconsistent estrogen levels, which cause a bunch of symptoms you may remember from The Golden Girls, like hot flashes, sleep disruptions, and mood swings. Unlike Blanche and Dorothy, however, you don’t have to be in your retirement years to experience perimenopause: It can start as early as your late 30s, though most often in your 40s.
If you have perimenopausal depression, you have all the typical depressive symptoms plus all the typical symptoms of perimenopause—so it’s no wonder you feel miserable. A final caveat: If you have a history of depression, you’re more likely to have a recurrence now; in fact, your chances of developing perimenopausal depression is 59%, vs 28% odds for women with no prior depression. (After your hormone fluctuations stabilize at menopause, your odds of postmenopausal depression decrease.)
Still, the root cause can be hard to pinpoint, which is why clinicians published the first guidelines for detecting and treating perimenopausal depression in 2018. If your low energy is caused by night sweats and losing sleep, estrogen may be the best treatment. If you have a history of depression, antidepressants might do the trick. If the pressures of job and family are at the center, therapy with or without antidepressants could be the answer. So be vigilant! If you’re middle-aged and you notice that doing the things you used to love no longer bring you joy, or you feel excessively guilty, hopeless, or sad, make a doctor’s appointment to discuss whether you might have perimenopausal depression.
Substance/Medication-Induced Depressive Disorder
In this case, your depressive symptoms occur due to using a drug or discontinuing use of a drug or to the drug making the depression you already had worse. It also doesn’t matter if the drug is legal or illegal—alcohol, tobacco, caffeine, cannabis, hallucinogens, opiates, inhalants, sedatives, and stimulants all count, according to the DSM-5. Even prescription medications taken for health conditions—like painkillers, statins for high cholesterol, and beta blockers for high blood pressure—can have depressive side effects. There are all types of reasons someone can wind up with Substance/Medication-Induced Depressive Disorder, from a reaction in their brain chemistry to a history of substance abuse. And there’s no telling how long the depression can last—it depends on what drug you’re on or were on, how long you are/were on it, if you have addiction issues, etc.
If you’re taking mood-altering substances of any sort and you’re feeling depressed, check in with a doctor. Remember, it’s important to be totally honest about which drugs and medications you’re on (or just came off), even if they’re illegal. If you know you have an addiction problem, it’s even more important to get help. In most cases, physician-patient confidentiality prevents your doctor from discussing your details with anyone. (There are some exceptions, such as disclosures required by law, like mandatory reporting of abuse and threats of serious and imminent harm.)
Along with your standard depression treatment plan of therapy and antidepressants, you’ll likely need to address underlying addiction behaviors, too. Treatment may involve detoxing in a clinic, rehab, group therapy, and medications that relieve withdrawal symptoms or block the pleasure receptors in the brain that light up when you use your drug of choice.
It’s more commonly associated with other mental disorders like schizophrenia and bipolar disorder, but in severe cases of depression, some people experience a break with reality called psychosis. Along with the typical symptoms of clinical depression, people experiencing psychosis have both:
Delusions: false beliefs, usually hypochondriacal ones about being ill, or of being guilty of something
Hallucinations: false perceptions, like hearing or seeing things that aren’t there
Psychosis is particularly dangerous, since depressive delusions often revolve around feelings of guilt or worthlessness. This warping of reality can quickly manifest as suicidal thoughts. Most people in the middle of a psychotic episode don’t realize that they’re sick, so if someone you know is dealing with severe depression, keep an eye out for these out-of-character symptoms. It’s important to get someone with psychotic depressions help ASAP. Typically, treatment occurs in a hospital with a combination of antipsychotic medications and antidepressants or electroconvulsive therapy (ECT).
This isn’t as bleak as it sounds. If you have treatment-resistant depression, that doesn’t mean you’ll never respond to treatment, only that you’ve had two or more adequate failed trials with antidepressants of two different classes and haven’t yet found relief.
For example, if you’ve tried an SSRI like Prozac (fluoxetine) and an SNRI like Pristiq (desvenlafaxine), or an SNRI like Cymbalta (duloxetine) and an MAOI like Marplan (isocarboxazid), etc., your depression could be defined as treatment resistant.
It’s important that you really give these medications an adequate trial at an adequate dose before throwing in the towel. You can’t just say "I've been on five medications, and I didn't respond to any," if what you mean is "I took Prozac for two days, and I had a bad side effect, so then I switched to Cymbalta." If your doctor determines that it’s time to try new methods, they might suggest electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), or other treatment options.
Disruptive Mood Regulation Disorder (DMDD)
Temper tantrums and moodiness are common among children (especially when you take away their iPad, yeesh), but if your kid has this disorder, you’ll see behavior that’s much more aggressive and extreme. They’re in a bad mood nearly all the time. They are extremely irritable and have severe, explosive outbursts with parents, teachers, and other kids several times a week. Their overreactions and tantrums are not consistent with their level of development—they’d make more sense coming from a younger child. To be diagnosed with it, kids must present the symptoms mentioned above three or more times per week for at least a year, have difficulty functioning at home and in school, and be between 6 and 18 years old.
In the past, kids exhibiting these severe symptoms would likely have been diagnosed with bipolar disorder and prescribed atypical antipsychotics. As time went by, doctors learned that most of these children didn’t go on to develop bipolar disorder—but they did develop clinical depression and anxiety. To emphasize its mood component and separate it from bipolar disorder since there is no manic phase, DMDD was added to the DSM-5 in 2013. Treatment is often a behavioral therapy/parent management training combo, focused on specific strategies for disruptive behavior, with or without medication (typically SSRIs or low-dose atypical antipsychotics).
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