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What is Major depression?
Everyone feels sad from time to time. It is an experience that every person, sooner or later, more or less frequently, goes through at some point in their life.
However, if all the activities you once considered enjoyable have completely lost their appeal, you may be facing something more serious, because being habitually depressed can change the way you think and experience life.
Doctors define this condition as major depression (or major depressive disorder).
In Europe, according to the latest Eurostat data, approximately 5.5% of the population is affected, with a clear predominance of women over men (nearly double the rate). Analyzing prevalence across different age groups reveals that the risk of developing this disorder increases with age. European citizens living in urban areas are associated with a higher probability of reporting chronic depression, although in some countries this pattern reverses.
There are many reasons why depression so often goes undiagnosed and untreated, but one of the most common is that it can present with significantly different symptoms from one patient to another.
Depression can manifest, for example, as unusual fatigue, as low mood, or as irritability. Problems with mental confusion or attention difficulties caused by depression can sometimes be mistaken for Alzheimer’s disease or other mental health problems in elderly patients, and for stress in younger individuals. Mood changes and depression symptoms can even be caused by medications that elderly patients take for osteoarthritis, high blood pressure, or heart disease.
Being in a low mood for an extended period is not a normal condition, but rather a sign of an increasingly common problem that may require medical attention. For most people, depression will improve or resolve completely after appropriate treatment, whether psychological, pharmacological, or otherwise.
What Is the Difference Between Low Mood and Depression?
Low mood can cause:
- sadness,
- feelings of anxiety up to the development of panic,
- worry,
- fatigue,
- low self-esteem,
- frustration,
- anger,
but these symptoms tend to resolve within a few days or weeks.
Some small changes, such as resolving a difficult situation, talking about problems with family members or friends, or simply getting more sleep, are generally enough to improve the situation.
Persistent low mood that does not improve, on the other hand, may be a sign of depression. Symptoms of depression can therefore include:
- a low mood lasting two weeks or longer,
- inability to derive pleasure from situations or social interactions that are normally enjoyable,
- feeling hopeless,
- fatigue and lack of energy,
- inability to concentrate on simple tasks, such as reading the newspaper or watching television,
- appetite disturbances,
- sleeping more than usual or no longer being able to sleep enough,
- suicidal thoughts.
Causes
The cause of depression is never singular.
Only in some cases can the illness be triggered by a single event. For example, depression can strike people who previously felt well but suddenly find themselves facing a family bereavement or a serious illness.
In other cases, changes in the nervous system influence mood and cause depression. Sometimes people under extreme stress, such as those caring for elderly relatives, children, or sick family members, may become depressed. Other people, finally, fall into depression without any identifiable reason.
In some cases, depression is a consequence of a serious illness, such as:
- cancer,
- diabetes,
- heart disease,
- heart attacks,
- stroke,
- Parkinson’s disease.
In these patients, the trigger for depression is the worry about the impact of the illness on their lives. They may feel too tired to cope with something that makes them sad. Treatment for depression can help them manage depressive symptoms and improve their quality of life.
Genetic factors also play an important role. Some research demonstrates that depression can have hereditary traits; children of depressed parents may therefore be at higher risk of developing depression themselves.
Depression is also a condition that tends to be recurrent, meaning that people who have experienced depression in the past will be at greater risk of future episodes.
Risk Factors
- Women are more frequently affected than men.
- Depression can occur at any age, but it most commonly manifests in adults.
- In the presence of serious medical conditions (diabetes, cancer, heart disease, Parkinson’s disease, and others), the risk of developing depression is higher.
- Family history of depression.
- Traumatic and/or stressful events (bereavement, job loss, financial difficulties, and others).
It has long been known that certain medications can predispose individuals to developing depression, but according to some researchers, the impact in terms of both scope and variety of medications involved may be greater than commonly thought. A study published in JAMA (a prestigious American scientific journal) found that more than 200 relatively commonly used molecules may be associated with depression (birth control pills, certain medications for high blood pressure and heart conditions, painkillers, stomach medications, and others).
While this study has evident limitations (it is based on analysis of data collected through questionnaires) and it is important to remember that what emerges is an association rather than a necessarily causal relationship, it is certainly an important factor to consider, especially in cases of polypharmacy (the use of multiple medications simultaneously). There is no proven direct cause-and-effect relationship; the explanation could, for example, involve a third factor linked to both (for instance, the underlying illness requiring medication could itself be the trigger for distress that eventually evolves into depression).
Classification
Depression (clinical depression or major depressive disorder) is a mood disorder that is both very common and, in some cases, very serious. Some forms of depression are slightly different, or may develop following exceptional events, including:
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Persistent depressive disorder (also known as dysthymia) is a mood disorder lasting at least two years. A person with persistent depressive disorder may experience episodes of major depression alternating with periods of less severe symptoms. However, symptoms must persist for at least two years for a diagnosis of persistent depressive disorder to be made.
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Perinatal depression is much more serious than the “baby blues” (relatively mild symptoms of depression and anxiety that typically disappear within two weeks of delivery), which affects many women shortly after childbirth. Perinatal depression involves the full onset of major depression during pregnancy or after delivery (postpartum depression). The extreme feelings of sadness, anxiety, and fatigue that accompany perinatal depression can make it difficult for affected mothers to care for themselves and their newborns.
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Psychotic depression occurs when a person suffers from severe depression combined with some form of psychosis, such as delusions (frightening, obsessive false beliefs) or hallucinations (seeing or hearing disturbing things that others cannot perceive). Psychotic symptoms typically have a depressive theme, such as delusions of guilt, poverty, or illness.
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Seasonal affective disorder is characterized by the onset of depression during the winter months, when there is less natural light. This form of depression generally improves in spring and summer. In this disorder, winter depression, typically accompanied by social withdrawal, increased sleep, and weight gain, predictably recurs every year.
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Bipolar disorder is different from depression, but is included in this list because a person with this disorder periodically experiences extreme drops in mood that meet the criteria for major depression (“bipolar depression”). However, a person with bipolar depression also goes through phases of extremely elevated or irritable mood, known as episodes of “mania”, or milder phases of “hypomania”.
Examples of other forms of depressive disorders recently included in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition) include:
- disruptive mood dysregulation disorder (recognized in children and adolescents),
- and premenstrual dysphoric disorder (PMDD).
Symptoms
Major depression can manifest through a wide range of symptoms, which can be very different from one another and vary profoundly from one patient to the next. Symptoms include feeling sad, experiencing a complete lack of hope about the future, and losing interest in all activities. It is also very common to experience typical anxiety symptoms alongside depression.
Many patients also report physical (somatic) symptoms, such as fatigue, sleep disturbances, loss of appetite and sexual desire, as well as various types of pain.
If symptoms are mild, they may be linked only to a temporary phase, as happens to everyone during periods of stress or difficulty, and in these cases the tendency is toward improvement within a short time. However, if you suffer from major depression and do not seek treatment, it can persist for weeks, months, or even years. Below is a list of the most common symptoms of depression. If some of these are part of your experience and have lasted more than two weeks, we recommend consulting a doctor.
- a feeling of “emptiness”, continuous sadness, and anxiety,
- fatigue and lack of energy,
- loss of interest or pleasure in daily activities (including sex),
- sleep disturbances, such as:
- difficulty falling asleep,
- waking up very early in the morning,
- excessive desire to sleep,
- appetite greater or less than usual,
- frequent or excessive crying,
- aches and pains that do not resolve even after treatment,
- difficulty concentrating or remembering things,
- inability to make decisions,
- feelings of guilt,
- feeling helpless, worthless, and/or hopeless,
- irritability,
- thoughts of death or suicidal fantasies (or attempted suicide).
If you are a family member, friend, or doctor of a person at risk, pay close attention to the symptoms. Sometimes depression can hide behind a smiling face; a depressed person living alone may appear relieved if someone stops checking in on them. The symptoms may seem to have disappeared, but if a person is severely depressed, they tend to return.
Warning signs should never be underestimated: if left untreated, severe depression can lead to suicide. Pay attention if someone, regardless of age, says they feel depressed or that others do not take them seriously. That person may genuinely be seeking help.
Not all individuals affected by depression experience the full range of possible symptoms, and the severity of those symptoms can also vary significantly.
Diagnosis
The diagnosis of major depression is a rigorous clinical process that goes beyond simply detecting sadness; it evaluates the overall impact of the disorder on the patient’s life. The diagnostic gold standard is based on the criteria of the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders) and the ICD-11.
For a major depressive episode to be diagnosed, at least five symptoms must be present for a minimum period of two weeks, representing a change from the person’s previous level of functioning. Among these symptoms, at least one of the two cardinal features must be present: depressed mood for most of the day, or marked loss of interest or pleasure (anhedonia) in nearly all activities.
The Diagnostic Process
The doctor typically follows a structured diagnostic pathway that includes:
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Clinical interview: This is the primary diagnostic tool. The doctor investigates the history of symptoms, their duration, intensity, and the presence of thoughts related to self-harm or suicide. Family history and the possible presence of previous episodes are also evaluated.
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Physical examination and laboratory tests: These are essential for ruling out organic causes (“differential diagnosis”). The doctor may order blood tests to assess thyroid function (to rule out hypothyroidism), vitamin B12 and folic acid levels, kidney and liver function, or the presence of severe anemia, all of which are conditions that can mimic depressive symptoms.
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Screening tests and assessment scales: Standardized questionnaires are often used, such as the PHQ-9 (Patient Health Questionnaire) or the Hamilton Depression Rating Scale. These tests help quantify the severity of the disorder and monitor treatment progress over time, but they never replace the clinical interview with a professional.
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Specialist psychiatric evaluation: In complex cases, when symptoms are severe or when there is suspicion of other overlapping conditions (such as bipolar disorder or psychotic features), the involvement of a psychiatrist is necessary to better define the psychopathological profile and develop the treatment plan.
It is important to note that the diagnosis also takes into account the patient’s cultural and social context, distinguishing clinical depression from normal grief reactions or adjustment to adverse life events, although the latter can sometimes evolve into a true depressive disorder.
When to Call a Doctor
The first step is recognizing that you or your loved one genuinely needs help.
You may feel very uncomfortable at the idea of discussing a mental health condition, or you may think that asking for help is a sign of weakness. You may reason like many other patients, or their relatives and friends, who believe that a depressed person can pull themselves together quickly, or that some people are simply too old to be helped.
Nothing could be further from the truth!
A doctor can help you, and you can confidently turn to your primary care physician. The doctor will check whether the depression is caused by a health problem (such as hypothyroidism or a vitamin B12 deficiency) or by a medication you are currently taking. After a complete examination, they may recommend that you see a mental health specialist, such as a psychologist or psychiatrist.
Do not refuse treatment out of fear of cost. Often, only a short course of psychotherapy is needed, and treatment for depression can be covered by the national healthcare system.
Are you a family member or friend of a depressed patient who refuses to see a doctor?
Try to explain how treatment can help them feel better. In some cases, if the depressed person cannot or will not go to a doctor’s office, the doctor or specialist can begin by making contact by phone. A phone call cannot replace the in-person interaction needed for a complete diagnosis, but it can convince the person to seek treatment.
Treatment and Care
The primary goal of major depression treatment is complete remission of symptoms and restoration of the patient’s social and occupational functioning. The modern approach is multidisciplinary and personalized (“tailored therapy”), combining psychological interventions, pharmacological treatments, and lifestyle modifications.
Psychotherapy
For mild to moderate forms, psychotherapy is often considered the first-choice treatment. The most effective forms according to scientific consensus are:
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Cognitive-Behavioral Therapy (CBT): Helps the patient identify and modify negative thought patterns (cognitive distortions) and dysfunctional behaviors that fuel depression.
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Interpersonal Therapy (IPT): Focuses on the patient’s social relationships and life events (bereavement, conflicts, role changes) that may have triggered or worsened the depressive state.
Pharmacotherapy
Antidepressant medications are essential in moderate to severe forms or when psychotherapy alone is insufficient. The most commonly used drug classes include:
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Selective Serotonin Reuptake Inhibitors (SSRIs): These are the most prescribed antidepressants due to their favorable safety and tolerability profile.
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Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Often used when physical symptoms or chronic pain are also present alongside depression.
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Newer approaches (esketamine): For depression resistant to common treatments, innovative therapies with controlled administration are now available that act on the glutamate system, offering a more rapid response in selected cases.
It is crucial to know that antidepressants typically require 2 to 4 weeks to show initial benefits, and that treatment should never be stopped abruptly to avoid withdrawal symptoms.
Supportive Interventions and Complementary Therapies
Beyond standard treatments, there are approaches that can enhance the recovery process:
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Music therapy: As confirmed by recent analyses from the Cochrane Library, music therapy combined with conventional treatments significantly reduces anxiety and depressive symptoms, improving relational quality of life.
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Neuromodulation (rTMS): Repetitive Transcranial Magnetic Stimulation is a non-invasive technique used in hospital settings for patients who do not respond to medications.
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Electroconvulsive therapy: More commonly known as electroshock therapy, this is now performed under general anesthesia and only in cases of very severe depression with life-threatening risk or total resistance to other treatments. Although controversial, it remains a life-saving intervention with proven clinical efficacy.
Lifestyle and Self-Care
Changing daily habits is not optional but an integral part of treatment. Regular physical activity (at least 150 minutes per week of moderate exercise such as brisk walking) has an antidepressant effect comparable in some cases to medication in mild forms, thanks to the release of endorphins and the promotion of neuroplasticity.
It is also essential to maintain good sleep hygiene (keeping regular sleep and wake times), avoid alcohol use (which is a powerful depressant of the nervous system), and follow a balanced diet rich in nutrients essential for brain health. The social support of family and friends, when empathetic and non-judgmental, significantly accelerates recovery times.
Prevention
What can you do to reduce the risk of depression? What can you do to overcome it? Here are some recommendations worth following.
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Try to prepare yourself for major life changes, such as retirement or moving from a home you have lived in for many years. One way to stay prepared is to nurture friendships over the years. Friends help combat loneliness if you become widowed or find yourself alone.
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You can also dedicate yourself to a hobby. Pastimes can help keep your mind and body active.
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Do not lose touch with your family. Ask your relatives for help when you feel very sad.
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If you are facing something truly overwhelming, try to break it down into smaller, more manageable tasks that are easier to complete.
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Regular physical exercise can also help prevent depression or improve your mood if you are feeling depressed. Moderate physical activities, such as walking, can benefit older adults suffering from depression, both physically and mentally. Gardening, dancing, and swimming are also effective. Choose a physical activity you enjoy: start with perhaps 10 to 15 minutes per day, and then, if you can, gradually increase the time you dedicate to it. Staying fit and following a balanced diet can help prevent the diseases that can cause disability or depression.
Finally, remember that with appropriate treatment, most people begin to improve within a relatively short time. Complete recovery, however, requires patience. It takes time to feel better, but healing is possible.
Frequently Asked Questions
What is major depression?
Major depression (or major depressive disorder) is a serious mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable. It significantly interferes with a person’s ability to function in daily life.
What are the main symptoms?
The most common symptoms include persistent sadness or emptiness, loss of interest in activities, fatigue, sleep disturbances, appetite changes, difficulty concentrating, feelings of worthlessness or guilt, and in severe cases, thoughts of death or suicide.
What causes depression?
Depression never has a single cause. It typically results from a combination of genetic, biological, environmental, and psychological factors. Serious medical conditions, chronic stress, traumatic events, and certain medications can all contribute to its development.
How is depression treated?
Treatment typically involves psychotherapy (such as Cognitive-Behavioral Therapy or Interpersonal Therapy), antidepressant medications (such as SSRIs or SNRIs), lifestyle changes including regular exercise, or a combination of these approaches. In severe or treatment-resistant cases, neuromodulation techniques or electroconvulsive therapy may be considered.
Can depression be prevented?
While not all cases can be prevented, maintaining regular physical activity, nurturing social connections, managing stress effectively, getting adequate sleep, and seeking help early when symptoms appear can all significantly reduce the risk of developing depression.
How long does it take for antidepressants to work?
Antidepressants typically require 2 to 4 weeks to show initial benefits, with full therapeutic effects often taking 6 to 8 weeks. It is essential never to stop medication abruptly without medical guidance, as this can cause withdrawal symptoms.
Sources and Bibliography
- Eurostat Health Data
- Prevalence of Prescription Medications With Depression as a Potential Adverse Effect Among Adults in the United States - JAMA
- DSM-5 - American Psychiatric Association
- Music therapy for depression - Cochrane Review
- National Institute of Mental Health (NIMH) - Depression
- NHS Inform - Low mood and depression
- Mayo Clinic - Depression (Major Depressive Disorder)
- World Health Organization - Depressive Disorder
