Understanding Severe Depression

MDD with less severe depressive symptoms can be painful and difficult for an individual to experience, explains Dr. Neil Puri, medical director of Menninger’s Adult Division and medical director for Menninger’s Center for Brain Stimulation and Menninger 360.

But it’s less likely to interfere with their overall ability to function and may not be life-threatening. Alternatively MDD sees typical depression symptoms exacerbated, such as suicidal thoughts.

Types of severe depression

MDD is the most recognized form of severe depression. But other depressive disorders can be extreme, and some further mental health concerns can also involve severe depressive episodes.

These include:

• bipolar disorder
• persistent depressive disorder (dysthymia)
• disruptive mood dysregulation disorder
• premenstrual dysphoric disorder
• substance-induced mood disorder

Treatment-resistant depression can also be difficult to cope with and severe, says Dr. Holly Schiff, a licensed clinical psychologist in Connecticut.

This is because individuals have tried other treatment methods that haven’t helped to alleviate depressive symptoms.

MDD can present in numerous ways, and you don’t have to experience all symptoms to be diagnosed with the concern. Again, there isn’t an actual diagnosis of severe depression, but symptoms can be specified as severe under the diagnosis of MDD.

To receive a diagnosis of recurrent or severe MDD, an individual has to meet at least five criteria, as detailed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR), for 2 weeks or more.

The criteria includes experiencing the following symptoms most of the day or nearly every day:

• depressed mood
• loss of interest or pleasure
• weight loss or gain
• insomnia or hypersomnia
• psychomotor agitation or impairment
• fatigue or loss of energy
• feeling worthless or excessive guilt
• decreased concentration
• thoughts of death or suicide
• recurrent thoughts of death (not just fear of dying)
• recurrent suicidal ideation without specific plan, or suicide attempt, or a specific plan for suicide

Puri says some with severe depression may also experience paranoid thinking or hallucinations.

A psychologist or psychiatrist can determine whether your symptoms meet the criteria. It’s important to note that children and teens may express symptoms differently, usually via irritability, anger, and somatic complaints, such as stomach aches.

To reach a diagnosis, they will “conduct a psychological evaluation, which may include a structured interview and standardized questionnaires to assess the severity of symptoms and their impact on daily life,” says Dr. Kristi K. Phillips, a licensed psychologist at Wayzata Bay Wellness. “They will also look for the presence of the hallmark symptoms of depression.”

Phillips adds that, in some instances, further tests, such as blood tests and a physical exam, may be conducted.

“Depression is complex, so it’s hard to know exactly what causes it,” says Schiff. “But it can happen for a variety of reasons.”

Some primary actors associated with the onset of severe depression are:

Family history

“A family history of depression can increase the risk of developing severe depression,” states Phillips.

For instance, studies show that children with a depressed parent are two to three times more likely to develop MDD. Scientists have also linked 178 different gene variations to those with MDD.

Our body’s natural chemicals and hormones may play a role in severe depression.

Dysregulation of dopamine (the “pleasure and reward” chemical) in the brain is a potential factor in MDD onset. And the hormones estrogen, progesterone, and cortisol are all linked to severe depression.

Trauma

Experiencing trauma early in life may increase chances of developing severe depression. “Physical, sexual, or emotional abuse can make you more vulnerable,” Schiff says.

An analysis of 4,652 individuals found those who experienced early life trauma were 3.7 times more likely to develop MDD. Meanwhile, a 2018 study saw those who faced childhood maltreatment were twice more likely to develop treatment-resistant or chronic depression.

Substance use

“Substance abuse can lead to depression, and depression can lead to substance abuse, creating a dangerous cycle,” explains Phillips.

Some with severe depression turn to substances to help manage their symptoms, while those with substance use disorders (SUDs) are at greater risk of developing depression. One study of SUD patients found that 97% also had depression, with almost three-quarters experiencing severe symptoms.

Physical health conditions

Research from 2021 found that experiencing three or more physical health conditions doubles an individual’s risk of developing depression. These conditions range from asthma and chronic back pain to arthritis and irritable bowel disease.

Furthermore, this risk increases with every additional health concern.

Schiff adds that some medications also encourage depression — with beta-blockers, blood pressure drugs, and proton pump inhibitors all linked to symptoms.

While there is currently no cure for depression, treatment options are available to help you manage your symptoms.

Treatment efficacy can vary depending on the severity of depression and its potential causes, so consider speaking with your healthcare professional about which options might be best for you.

1. Therapy

Therapy for MDD comes in various forms, but one of the most popular is cognitive behavioral therapy (CBT). CBT aims to change negative and distorted thought patterns and beliefs, and studies have found it effective in preventing MDD relapses.

Behavioral activation therapy helps the individual “identify activities they find pleasurable and engaging, to help improve coping,” says Schiff.

Meanwhile, Phillips notes that interpersonal therapy — which involves improving communication skills so you can address issues exacerbating your depression — may also be beneficial.

2. Medication

Around 8.9 million US adults take drugs to help manage MDD symptoms. Schiff says the main ones prescribed are:

• selective serotonin reuptake inhibitors (SSRIs)
• serotonin and norepinephrine reuptake inhibitors (SNRIs)
• tricyclic antidepressants
• monoamine oxidase inhibitors (MAOIs)

Studies have found antidepressant medications more effective than placebo in treating the condition.

Drugs targeting depression may “help to regulate brain chemistry and improve mood,” says Phillips. “However, they can take several weeks to take effect and may have side effects.”

3. Electroconvulsive therapy (ECT)

ECT involves the delivery of electric currents to the brain to cause a quick seizure — which, in turn, aids in reducing MDD symptoms.

It’s typically only given to those with severe or treatment-resistant depression, but studies find that 80% of patients with MDD experience “substantial improvement” following the therapy.

While it reduces symptoms quickly, several sessions may be required for lasting effects.

ECT is now generally considered safe, as it “has been modernized since its inception in the 1930s, and many side effects have been greatly reduced or eliminated,” says Puri. But some concern remains around potential side effects, such as mild memory loss.

4. Lifestyle changes

Adjustments to your everyday routine — such as with sleep, exercise, and diet — may aid in improving mood and reducing depressive symptoms, Phillips states.

For instance, practicing yoga and meditation is associated with reduced MDD symptoms, while eating more healthily has been linked to a decrease in major depression.

Severe depression can occur in the form of MDD but also within other mental health disorders, such as disruptive mood dysregulation disorder and bipolar disorder.

Those with severe depression can encounter various symptoms, such as difficulty carrying out everyday activities, withdrawal from friends and family, and suicidal thoughts.

Various treatments can aid symptoms. But “medications combined with therapy are the mainstay treatment for severe depression,” Puri says. Although those with suicidal beliefs “may need to be psychiatrically hospitalized.”

If yourself or a loved one is experiencing severe depression, contact a mental health professional to discuss potential treatments and steps forward.