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Major Depressive Disorder (MDD) / Depression

Brief Overview: Major Depressive Disorder (MDD), commonly referred to as depression, is a chronic mental health condition characterized by persistent low mood and/or loss of interest or pleasure, accompanied by cognitive, emotional, and physical symptoms that interfere with daily functioning. Episodes may be recurrent and range from mild to severe. Management focuses on symptom remission, relapse prevention, and restoration of function, using a combination of medication, psychotherapy, and lifestyle support.

Crisis Line Information: https://988lifeline.org/

Prevalence: According to Cleveland Clinic, “Depression is common. Researchers estimate that nearly 7% of adults in the United States have depression every year. More than 16% of U.S. adults — around 1 in 6 people — will experience depression at some point in their lifetime.”

Etiology:

  • Multifactorial, involving interactions between:
    • Neurotransmitter dysregulation (serotonin, norepinephrine, dopamine)
    • Genetic vulnerability
    • Psychosocial stressors (loss, trauma, chronic stress)
    • Medical conditions (chronic pain, neurologic or endocrine disease)
    • Certain medication, substance use
  • No single cause; often develops over time.

Risk Factors:

  • Personal or family history of depression
  • Female sex
  • Major life stressors or trauma
  • Chronic medical conditions (heart disease, diabetes, chronic pain)
  • Social isolation or loneliness
  • Substance use disorders
  • Low socioeconomic status
  • Postpartum period or caregiving burden

Commonly Associated Conditions:

  • Anxiety disorders
  • Posttraumatic stress disorder (PTSD)
  • Substance use disorders
  • Chronic pain syndromes
  • Sleep disorders (insomnia or hypersomnia)
  • Cardiovascular disease
  • Cognitive impairment (especially in older adults)
  • Neurodegenerative diseases (Alzheimer’s, Parkinson’s)
  • Stroke
  • MS
  • Seizure disorders
  • Cancer
  • Macular degeneration

Common Medications:

Medications are commonly combined with psychotherapy and require several weeks for full effect.

  • First-line antidepressants:
    • Selective serotonin reuptake inhibitors (SSRIs):
      • sertraline, fluoxetine, escitalopram, citalopram, paroxetine
    • Serotonin–norepinephrine reuptake inhibitors (SNRIs):
      • venlafaxine, duloxetine, desvenlafaxine
  • Other commonly used agents:
    • Bupropion (norepinephrine–dopamine reuptake inhibitor)
    • Mirtazapine (often helpful for poor appetite or insomnia)
    • Trazodone – often for insomnia
    • Tricyclic antidepressants (TCAs) – used less often due to side effects
    • Atypical antipsychotics (e.g., aripiprazole, quetiapine) as augmentation in treatment-resistant depression
  • Adjunctive medications for late-life depression: methylphenidate, aripiprazole, lithium, triiodothyronine
  • Key medication counseling points:
    • Effects are gradual (often 2–6 weeks).
    • Do not stop abruptly without guidance.
    • Caution with medication choice with certain comorbidities, as some medical conditions can be exacerbated by certain antidepressant agents
    • Prescriber/patient should monitor for side effects and worsening mood or suicidal thoughts, especially early in treatment.

Common Labs, Imaging, and Tests:

  • PHQ-9
  • GAD-7 (for anxiety)
  • TSH, Vitamin B12, CBC, CMP

Common Symptoms: According to Cleveland Clinic, “The symptoms of depression can vary slightly depending on the type and can range from mild to severe. In general, symptoms include:

  • Feeling very sad, hopeless or worried. Children and adolescents with depression may be irritable rather than sad.
  • Not enjoying things that used to bring joy.
  • Being easily irritated or frustrated.
  • Eating too much or too little, which may result in weight gain or weight loss.
  • Trouble sleeping (insomnia) or sleeping too much (hypersomnia).
  • Having low energy or fatigue.
  • Having a difficult time concentrating, making decisions or remembering things.
  • Experiencing physical issues like headache, stomachache or sexual dysfunction.
  • Having thoughts of self-harm or suicide

If you or a loved one are thinking about suicide, dial 988 on your phone to reach the Suicide and Crisis Lifeline. Someone will be available to help you 24/7.”

Common Treatments:

  • Antidepressant medication (see above)
  • Psychotherapy (CBT, interpersonal therapy, supportive therapy)
  • Combination therapy for moderate–severe depression
  • Treatment of comorbid medical or psychiatric conditions
  • Referral to psychiatry for treatment-resistant or severe cases
  • Crisis intervention when safety concerns arise
  • Supplemental treatment – exercise, bright light therapy, mind-body interventions (yoga, tai chi, relaxation), acupuncture
  • Electroconvulsive therapy (ECT may be an option for some severe cases)

Physical Findings:

  • Often normal physical exam
  • Flat or tearful affect
  • Psychomotor retardation or agitation
  • Poor eye contact or slowed speech
  • Changes in weight or hygiene with more severe illness

Potential Complications and Contraindications:

  • Potential complications:
    • Suicide or self-harm
    • Functional decline and disability
    • Poor adherence to medical treatments
    • Worsening of chronic medical conditions
    • Social withdrawal and caregiver burden
    • Side effects from medications: weight gain/loss, somnolence, sexual dysfunction, GI side effects
  • Contraindications / cautions:
    • Antidepressant interactions with other medications
    • Increased fall risk in older adults
    • QT prolongation possible with citalopram and escitalopram
    • Bupropion contraindicated in individuals with seizure disorder or increased risk of seizure
    • Avoid venlafaxine in individuals with uncontrolled HTN
    • Black box warning for increased suicidal thoughts with certain medications
    • Careful monitoring required in bipolar disorder (risk of mania)

General Health and Lifestyle Guidance:

  • Encourage consistent medication adherence
  • Maintain regular sleep–wake schedule
  • Promote physical activity, even low-intensity movement
  • Encourage social connection and routine
  • Limit alcohol and avoid recreational drug use
  • Healthy nutrition and adequate hydration
  • Reinforce that depression is treatable and not a personal weakness

Suggested Questions to Ask Patients:

  • How have your mood and interest levels been recently?
  • Are you experiencing changes in sleep or appetite?
  • Are you taking your medication as prescribed? Any side effects?
  • Have you noticed any improvement since starting treatment?
  • What stressors are impacting you right now?
  • Do you have social or family support?

Suggested Talking Points:

  • Depression is a medical condition, not a personal failure.
  • Treatment takes time, but many people feel significantly better with the right plan.
  • Medications help rebalance brain chemistry, but therapy and routines matter too.
  • If symptoms worsen or you have thoughts of self-harm, seek help immediately.
  • You are not alone—support is available.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.