Approximately 332 million people worldwide have depression, according to the World Health Organization. Depression is about 1.5 times more common in women than in men, although it can affect people of any age, gender or background.
Recognizing depression symptoms is an important first step toward getting an evaluation and finding effective treatment.
[READ: Signs and Symptoms of Depression in Childhood]
What Is Clinical Depression (Major Depressive Disorder)?
Clinical depression, or major depressive disorder, is a mental health condition that causes persistent changes in how a person feels, thinks and functions.
“It’s different than when somebody says colloquially, ‘Oh, I feel depressed because the Dodgers lost their baseball game,” says Dr. David Merrill, an adult and geriatric psychiatrist and director of the Pacific Brain Health Center at Pacific Neuroscience Institute in Santa Monica, California.
It is more than temporary sadness following a disappointment, stressful day or difficult event. These normal feelings of sadness usually lessen with time and do not affect every aspect of daily life. With clinical depression, symptoms are more persistent and disruptive.
The difference between sadness and depression can be observed in the frequency, intensity, duration and level of impairment, says Judite Blanc, a research associate professor and assistant professor of psychiatry and behavioral sciences at the University of Miami.
For a diagnosis of major depressive disorder, a person generally must experience at least five of nine symptoms during the same two-week period. The symptoms must represent a change from the person’s usual functioning and cause significant distress or interfere with important areas of life.
A clinician will also consider whether the symptoms could be caused by a medication, substance use, a medical condition or another mental health disorder.
[READ: Baby Blues vs. Postpartum Depression: What’s the Difference?]
Clinical depression vs. normal sadness
| Feature | Normal sadness | Clinical depression |
| Duration | Short-term; improves with time | Persistent (2 or more weeks) |
| Intensity | Linked to specific event | Disproportionate to events |
| Functioning | Daily life continues | Significant impairment or distress |
[Read: How to Help Someone With Depression: 5 Expert-Backed Steps]
What Are the 9 Symptoms of Depression?
Depression is often pictured as visible sadness: low energy, frequent crying or an inability to get out of bed. Those can be signs, but depression may also appear in more vague or subtle ways, such as insomnia, fatigue or a decline in self-care.
“Signs people most often miss because they don’t look like sadness vary from irritability or anger to fatigue, pain, sleep disturbance and cognitive problems such as poor concentration or memory,” Blanc says.
Healthcare professionals often use the Patient Health Questionnaire-9, commonly called the PHQ-9, to screen for depression and track symptoms over time. The questionnaire asks how often a person has experienced each of the nine major depression symptoms.
Symptoms for major depressive disorder:
— Feeling sad, hopeless or despondent
— Loss of pleasure or interest in things you once enjoyed
— Sleep disturbances
— Loss of energy or fatigue
— Feelings of guilt or worthlessness
— Significant fluctuations in weight or appetite
— Difficulty concentrating
— Agitation or restlessness and psychomotor retardation or slowing
— Recurrent thoughts of death or suicide
1. Feeling sad, hopeless or despondent
A depressed mood may involve an overwhelming and persistent sense of sadness, hopelessness or despair. These feelings persist beyond the normal ups and downs of life and may make it hard to work, attend school, maintain relationships or complete basic tasks.
2. Loss of pleasure or interest in things you once enjoyed
Also called anhedonia, this looks like a pervasive and enduring lack of enjoyment or interest. A person may stop enjoying hobbies, social activities, food, intimacy or other experiences that once felt rewarding.
It does not always mean completely abandoning an activity. Someone may continue participating but feel numb, detached or unable to get the same satisfaction they used to.
3. Sleep disturbances
Sleep disturbances could mean sleeping too much or not enough.
A person with insomnia may have trouble falling asleep, wake frequently or awaken unusually early and be unable to return to sleep. Others may experience hypersomnia, meaning they’re sleeping much longer than usual but still feel exhausted during the day.
[The Truth About Depression in Older Adults]
4. Loss of energy or increased fatigue
Depression-related fatigue can be more severe than ordinary tiredness. Everyday responsibilities such as showering, preparing food, responding to messages or getting to work may feel overwhelming.
It’s important to evaluate the degree of disturbance that a lack of energy imposes on the person’s quality of life, says Dr. Timothy Sullivan, associate professor of psychiatry at the Zucker School of Medicine at Hofstra/Northwell in New York.
For example, if someone expresses that they don’t have as much energy as they used to, that may be mild depression. But if they say, ‘It’s been really hard to get to work, and I’ve been late a few days,’ then that may point to moderate depression.
Sullivan says more severe depression could look like someone who is having difficulty leaving the house or getting out of bed.
5. Feelings of guilt or worthlessness
The guilt category includes feeling guilty or feeling like you let yourself or others down. A person may feel inadequate, blame themselves for things outside their control or become consumed by past mistakes.
“That’s the question that usually brings out the tears because it’s the thing that they’ve been ruminating about,” Sullivan says.
For those who are people pleasers by nature, this one can be tough to distinguish. However, if there’s a significant change in your degree of guilt from how you normally are, or you’re specifically hung up on events that have triggered a depressive episode — like survivor’s guilt, for example — that may be a sign of something more serious, Merrill says.
He adds that survivor’s guilt can also become a part of post-traumatic stress disorder, highlighting that there’s a lot of overlap among mental health disorders like depressions, anxieties, psychosis and cognitive disorders, such as dementia.
6. Significant fluctuations in weight or appetite
Some people lose interest in food or skip meals, which may result in unintentional weight loss over a short period of time. Others eat more, experience cravings or turn to emotional eating as a way to cope, leading to weight gain. Either pattern can point to depression.
7. Difficulty concentrating
Depression may make it hard to follow a conversation, complete work or chores, remember appointments or make even simple decisions.
“Milder manifestations of that would be, ‘Tests are hard for me to read. I keep rereading the same sentence over and over,'” Sullivan explains.
From there, a moderate depressive symptom may mean someone who’s become forgetful. “They’re forgetting appointments and assignments,” Sullivan says.
Someone with severe depression is unable to complete cognitive tasks of which they should otherwise be capable, he says. “They can look at a newspaper, but it’s like they’re staring at it, nothing’s getting in.”
8. Agitation or restlessness and psychomotor retardation or slowing
Depression symptoms can include noticeable changes in a person’s movement, speech and reactions. These changes must be observable to other people, rather than only an internal feeling of restlessness or sluggishness.
Examples of psychomotor agitation may look like:
— Pacing or having trouble sitting still
— Fidgeting, hand-wringing or tapping the fingers or feet
— Appearing unusually impatient or on edge
Agitation or restlessness is particularly common in the elderly, Sullivan says.
Conversely, it is also common to see psychomotor retardation or slowing during major depressive episodes. This manifests as things like:
— Walking, speaking or responding more slowly than usual
— Taking longer to get dressed or complete other routine tasks
— Speaking quietly or in a flat, monotonous voice
— Moving sluggishly or appearing to stare into space
9. Recurrent thoughts of death or suicide
This can range from more passive thoughts about death to making a plan to kill oneself to actually having the intent to do it.
If people talk about it and share their feelings, there are effective options to intervene. Asking someone directly if they are thinking about hurting themselves does not encourage suicidal behavior and can open the door to getting them help.
Call or text 988 to reach the Suicide & Crisis Lifeline 24/7 if you or someone else is in emotional distress. You can also talk to someone online at https://chat.988lifeline.org. Call 911 or go to the nearest emergency department if there is immediate danger.
[READ: Reach the Suicide and Crisis Lifeline by Calling 988.]
How Signs of Depression Vary Across Ages and Gender
Depression symptoms can vary largely from person to person. Symptoms can vary by age, gender and culture, and, according to Blanc, many people continue working, parenting or caring for others despite significant distress.
Some frequently overlooked signs that people may not recognize in themselves or others include:
— Irritability, anger or impatience
— Unexplained pain or digestive symptoms
— Withdrawing from others
— Using alcohol or drugs to cope
— Staying constantly busy or working excessively to avoid emotions
Blanc says focusing too heavily on visible sadness and low energy can contribute to missed diagnoses. In her clinical work, she has also seen depression accompanied by poor hygiene or dissociation, a sense of disconnection from yourself or your surroundings.
However, here are common ways in which depression may manifest across ages and gender:
— Kids and teenagers
— Women
— Men
— Older adults
Kids and teenagers
Depression symptoms can manifest differently in kids than adults. Children and teens may appear irritable, argumentative or angry rather than sad. Because they may not have the words or self-awareness to explain what they are feeling, depression can be mistaken for defiance or a behavioral problem.
For example, a kid who has temper tantrums, mood swings or talks back to their parents may actually be depressed but may not be able to say so, Sullivan says. “They lack that capacity to see, ‘Why did I do what I did?'”
Other signs can include withdrawing from friends, falling grades, difficulty concentrating in class and trouble completing assignments.
“Difficulty with schoolwork is often where things first pop up and may look more like irritability or argumentativeness,” Sullivan says.
Adolescents with depression are also more likely to engage in risky behaviors, like substance abuse and self-harm behaviors.
[SEE: What Are Mood Disorders in Children?]
Women
Hormonal changes during pregnancy, after childbirth and around menopause may affect depression risk.
The loss of estrogen and hormonal fluctuations during menopause can disrupt the balance of the brain’s neurotransmitters, potentially leading to mood changes and depression.
Early menopause also can pose risks for late-life depression and dementia, Merrill says.
However, persistent symptoms should not automatically be dismissed as a normal part of hormonal change.
Blanc notes that depression may be underrecognized in women, including Black women, when it appears as sleep problems, irritability or physical symptoms rather than sadness. Some may also feel pressure to remain strong, suppress emotions and care for others despite their own distress, a pattern sometimes described in research as the “Superwoman Schema,” Blanc says.
Men
Men with depression may be more likely to show irritability, anger or frustration than sadness or vulnerability. Others may suppress emotions entirely and appear stoic on the outside.
Especially in men, you can have irritable depression, Merrill says.
Some may withdraw, work excessively or appear emotionally detached, making depression harder to recognize.
Older adults
“Older adults are less likely to explicitly endorse that they feel depressed,” Merrill says. This is likely due to generational differences.
Depression can also manifest more often as physical symptoms than emotional symptoms in older adults. For example, they may complain of chronic pain, headaches, fatigue and digestive issues, which — though it could point to signs of another medical condition — could be signs of depression. They’re also likely to feel more irritable and agitated.
New memory or concentration problems also warrant evaluation because depression can resemble or occur alongside cognitive disorders.
[READ: What to Do During a Mental Health Crisis]
What Causes Depression?
Depression is thought to be the result of a combination of genetic, biological, psychological, social and environmental factors.
As outlined by the NIMH, risk factors associated with higher rates of depression include:
— Having a personal or family history of depression
— Experiencing major life changes
— Trauma
— Stress
— Brain chemistry
— Certain physical ailments and medications, including drugs prescribed for conditions from controlling high blood pressure to treating asthma to helping with smoking cessation
— Serious and chronic medical illnesses, such as heart disease and diabetes.
— Early life adversity like childhood trauma — including physical or sexual abuse — which has also been linked to higher rates of depression, not only around the time of the trauma but later in life as well.
[READ: Is Depression Genetic or Environmental?]
How Is Depression Treated?
Depression treatment depends on the type and severity of symptoms, medical history and individual preference.
Psychotherapy, often called talk therapy, and antidepressants are commonly recommended together, especially for moderate to severe depression. Whether a person is selecting a therapist or therapeutic approach or trying different medications, it can take time to find the right fit.
Below is an overview of common therapies for depression:
— Psychotherapy. Cognitive behavioral therapy, interpersonal therapy and other forms of talk therapy can help people identify unhelpful thought patterns, build coping skills, improve relationships and address stress or trauma.
— Antidepressant. It can take time for you and your healthcare provider to find the medication and dose that provide the best balance of benefits and side effects. Here are some common medications:
— Selective serotonin reuptake inhibitors, commonly called SSRIs, are often used as a first-line treatment for depression because they are generally effective and well tolerated. Examples include sertraline (Zoloft) and escitalopram (Lexapro).
— Serotonin-norepinephrine reuptake inhibitors, or SNRIs, are another common option. Examples include duloxetine (Cymbalta) and venlafaxine (Effexor).
— Other antidepressants include dextromethorphan-bupropion (Auvelity), a newer combination medication approved for major depressive disorder in adults, and older options like tricyclic antidepressants.
— Exercise and lifestyle support. Extensive research shows that physical activity, such as strength training, yoga and moderate-intensity aerobic exercise like walking or jogging, can help reduce depression symptoms. Healthy sleep habits, nutritious meals, social connection and limiting alcohol also support overall mental health and well-being, but these steps do not replace professional care when depression symptoms are severe.
— Ketamine-based treatments. Intravenous ketamine is sometimes used off-label for difficult-to-treat depression. Esketamine nasal spray (Spravato) is FDA-approved for treatment-resistant depression, either alone or with an antidepressant, and for depressive symptoms in adults with major depressive disorder and acute suicidal ideation or behavior. It must be given in a certified health care setting with monitoring for at least two hours after administration.
— Hospital care. In severe cases, individuals may benefit from inpatient hospitalization — either voluntarily or against their will in some cases. When someone is an active danger to themselves or those around them, this may be the most appropriate course of treatment. For example, if there’s an active intent to commit suicide, “where they have both formulated a plan, and they have the intent to carry that out,” Merrill says, then they’re likely in need of hospitalization for round-the-clock care.
— Brain stimulation. With treatment-resistant depression — which is when those have long-lasting and hard-to-treat depression that does not respond to traditional medications — your psychiatrist may determine you’d potentially benefit from further interventions such as transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT) or vagus nerve stimulation.
[READ: Burnout vs. Depression: How to Tell the Difference]
Types of Depression Disorders
In addition to major depressive disorder, there are a number of other types of depression.
The National Institute of Mental Health lists several examples:
— Persistent depressive disorder
— Perinatal or postpartum depression
— Psychotic depression
— Seasonal affective disorder
— Depression occurring with bipolar disorder
Depression is commonly accompanied by anxiety as well, requiring individuals to manage both at the same time.
Persistent depressive disorder
Persistent depressive disorder, formerly called dysthymia, is a long-lasting form of depression. Depressed mood is present most of the day, more days than not, for at least two years in adults or one year in children and adolescents.
In addition to depressed mood, at least two of these symptoms are present:
— Poor appetite or overeating
— Insomnia or excessive sleep
— Low energy
— Low self-esteem
— Poor concentration or trouble making decisions
— Hopelessness
This is a separate symptom list from the nine symptoms used to diagnose a major depressive episode. A person with persistent depressive disorder can also experience periods that meet the full criteria for major depression.
This form of chronic, low-to-moderate levels of depression is not as severe as major depression, but the ongoing nature of this disorder can significantly interfere with a person’s life and relationships.
Perinatal or postpartum depression
Perinatal depression occurs during pregnancy or after delivery — which, in the latter case, is typically referred to as postpartum depression. Symptoms may include intense sadness, anxiety, crying, exhaustion, appetite changes, trouble sleeping even when the baby sleeps and difficulty bonding with or caring for the baby.
Treatment can include psychotherapy and prescription antidepressants. Zuranolone, brand name Zurzuvae, is an oral medication approved specifically for postpartum depression and is taken for 14 days.
Depression with psychotic features
Severe depression can occur with symptoms of psychosis, including delusions, or false beliefs, and hallucinations — seeing or hearing things that aren’t there. These delusions and hallucinations are frequently related to the person’s depressed feelings, such as believing they have committed an unforgivable act or hearing a voice that says they do not deserve to live.
Treatment can include psychotherapy and prescription medications, including antidepressants and/or antipsychotics. Hospitalization is sometimes necessary.
Postpartum psychosis occurs after childbirth, involving symptoms such as hallucinations, delusions, severe confusion or mania and requires urgent medical care.
Seasonal affective disorder
Also referred to as seasonal or winter depression, seasonal affective disorder is depression that follows a recurring seasonal pattern, most commonly beginning in fall or winter and improving in spring.
Treatment approaches include light therapy — or exposure to artificial light — as well as therapy and medication traditionally prescribed for depression. Bupropion (available as a generic drug and under brand names Wellbutrin XL and Aplenzin) is an antidepressant that’s used to treat depression and is also specifically FDA approved for seasonal affective disorder.
Depression in bipolar disorder
Bipolar disorder is not the same as major depressive disorder, but it is a mood disorder that includes episodes of depression.
The two main subtypes are:
— Bipolar I disorder. Requires at least one manic episode. Mania involves a period of unusually elevated, expansive or irritable mood and extreme energy that lasts at least one week or is severe enough to require hospitalization.
— Bipolar II disorder. Involves at least one major depressive episode and at least one hypomanic episode. Hypomania lasts at least four days and is less severe than mania.
Some people have bipolar disorder with mixed features during which they experience both manic and depressive symptoms within the same episode.
Treatment typically involves psychotherapy and prescription medications, including mood stabilizers, antipsychotics and/or antidepressants.
[READ: Types of Therapy: Choosing the Right One for You.]
When to Seek Help for Depression
Experts advise people who suspect they or a loved one are suffering from depression to seek professional help so they can be properly diagnosed and treated. In particular, anyone who is having suicidal thoughts, experiencing psychosis or whose safety might otherwise be compromised is urged to get help immediately.
“Depression is a very serious mood disorder that you should not take lightly,” Blanc says. “The moment you start noticing that changes in your feelings, thoughts and behavior persist for at least two weeks in a row, you should seek professional help.”
You do not need to wait until you have every symptom or can no longer function.
Blanc encourages affected individuals and their loved ones to seek help from a licensed mental health professional for an evaluation and to identify the best treatment strategies for their circumstances. Earlier support may keep symptoms from worsening and even save lives.
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A Guide to Clinical Depression: Signs and Symptoms and Treatments for Major Depressive Disorder originally appeared on usnews.com
