There are no diagnostic tests for depression.
What I mean is, we can’t draw someone’s blood to look for a specific “depression” blood marker, nor can we look at someone’s DNA to see if they have the “depression” gene.
We can, of course, look at the brain using highly specialized brain scanners, and researchers are beginning to see patterns of abnormal structure and function in depressed patients.1 But these patterns vary between patients, which suggests that depression is a highly complex, multifactorial and variable disease.
It can look one way in one patient, and very different in another.
So diagnosing depression is currently based, not on a set of commonly defined physiological or neurobiological factors, but on a person’s symptoms.
Clinical Symptoms of Depression
The American Psychiatric Association has published the definitive list of these symptoms in the Diagnostic and Statistical Manual of Mental Disorders.2 You have Major Depressive Disorder (MDD) if you experience at least five of the following nine symptoms on most days for two weeks or more:
A major depressive episode is defined as a period when these symptoms can’t be attributed to any other illness or substance/drug you are currently taking, and are severe enough to impair your normal routine or relationships.
Remember that an MDD diagnosis only requires having five of the nine symptoms, and not everyone experiences the same subset of five. So mathematically speaking, there are literally hundreds of different combinations of symptoms that would all qualify for MDD.
That fact alone is a little mind-blowing. It again highlights the fact that depression is an extremely complex disease.
Let’s look at the symptoms in more detail. You will find, as I do, that some resonate more with your own experience than others.
The first 2 symptoms are the most fundamental: all MDD patients feel “depressed” (sad, empty, hopeless) and/or lose interest in work, hobbies, social gatherings, or other activities that usually bring them pleasure.
American Poet Henry Wadsworth Longfellow expressed it this way: “Every man has his secret sorrows which the world knows not; and often times we call a man cold when he is only sad.”
Some will substitute feelings of physical pain, like body aches and pains, for emotional pain. Others will feel more irritable than usual, with a shorter fuse and an exaggerated sense of frustration over minor matters.
This is especially true of children and adolescents, who often become irritable and anxious rather than sad.3 Depression is often missed in these age groups because it can manifest as unexplained physical symptoms, behavioral problems, eating disorders, refusal to go to school or spend time with friends, and/or substance abuse. Growing up, I don’t think my parents recognized my depression since it was often masked as anger and frustration.
And I found that my irritability fed directly into the second symptom: apathy. Like the first, this symptom is nearly always present in depressive episodes. I am an introvert by nature, but depressive apathy made me lose all interest in spending time with other people.
The result is, of course, that I fell out of mainstream life. During high school and college, I broke up with boyfriends over their annoying pleas to spend more time together and avoided my friends. I far preferred to lie on the floor of my room, reading the same book over and over, or just thinking about…well, nothing in particular.
I still struggled with this symptom after I got married, because I would distance myself even from my husband and children. Most people became no more than unwelcome phantoms in my murky world. I found their presence – and attempts to interact with me – uncomfortably jarring.
Here is the tragedy of this symptom: it is the depressed individuals themselves who eventually become the phantoms. Mainstream life keeps flowing on without us.
We live alone in our self-imposed fog of depression, lonely and isolated, but unable or unwilling to make our way back. During depressive episodes, sometimes it just seems easier to push further into the fog.
At least four other symptoms must be present in order to qualify as a major depressive episode.
Many experience changes in appetite and weight – weight gain seems to be more common than weight loss.
Many also experience sleep disturbances. I have struggled with “initial” insomnia (the inability to fall sleep) since I was a teenager. But the more common problems are either “middle” insomnia (waking up in the middle of the night and unable get back to sleep) or “terminal” insomnia (waking too early). Others with depression have hypersomnia (sleeping more at night or taking more daytime naps than usual).
But really, no amount of sleep seems to be enough to restore the physical strength it takes to carry the dead weight of depression. For me, this created a dragging sense of exhaustion, as if I was moving in slow motion all the time.
American novelist Jasmine Warga described it this way: “Depression is like a heaviness that you can’t ever escape. It crushes down on you, making even the smallest things like tying your shoes or chewing on toast seem like a twenty-mile hike uphill.”4
Many also experience feelings of guilt and worthlessness. Blaming oneself for shortcomings at work or in relationships is quite common, so this alone is insufficient to qualify as a depressive symptom. But such pangs are only the shallows of guilt; depressed individuals can stray into much deeper waters. They can spend countless hours ruminating over character defects and failures.
This, by the way, is why attempts to “shame” someone out of depression — “Why do you have to act like this? I’m sick of it! Snap out of it!” — are bound to fail, and in two respects: 1) when an external voice chimes in with the internal one, it only serves to reinforce one’s low opinion of oneself, and 2) the external voice is rarely, if ever, more severe than the internal one.
Difficulty concentrating or remembering things can also be symptoms of depression. In the elderly, these can be misdiagnosed as dementia. In the young, depressed-induced cognitive impairment can translate into poor grades.
It’s hard to describe this lack of clarity to someone who has never experienced it. Hungarian writer and journalist Sándor Márai comes as close as anyone: “You would like to read, but somehow the rain gets into the book, too; not literally, and yet it really does, the letters are meaningless, and all you hear is the rain.”5
Some depressive symptoms are more common than others.
Sleep disturbances and fatigue show up fairly regularly and are often the first symptoms the patient will feel, though he or she may not necessarily link them to depression. But sleep issues/fatigue may become so bad that they drive the patient to seek medical help, thus can also initiate treatment for depression (provided the healthcare professionals involved are on their toes and detect the other symptoms).
Delusional or near-delusional guilt (such as believing that one is single-handedly responsible for global warming) are less common, but their presence, as well as psychomotor disturbances like severe agitation, indicate a more severe depression.
Severest of all symptoms are recurrent thoughts of death or suicide. Besides apathy, this symptom is the one that makes the least sense to those who have never experienced depression. Feelings of suicidality can be quite divisive, creating feelings of anger, hostility, and betrayal in both the suicidal individual and those in his/her social circle.
I think most would agree that life is a precious and sacred gift, one that should never be thrown away. But I can also say – from personal experience – that even such deeply-held convictions do not always stop the dark thoughts from coming.
In the deepest shadow-times of my own life, I have wanted to die.
It is just one of the many paradoxes of depression that seem impossible to explain.
But I’d like to say one thing. Let me preface it by saying that it should not in any way be construed as condoning death as a way of escape, but simply as a way to see the suicidal impulse from the inside, from the depressed individual’s perspective.
Okay, here is what I wanted to say. If you have had suicidal thoughts yourself, or know others with such thoughts, it may help to understand that almost all known motives for suicide are at their core an abandoned hope:
- the inability to see joy in the future,
- the urge to escape seemingly insurmountable difficulties,
- or the desire to end pain.
The loss of hope extinguishes the desire to live.
And this is how severely depressed individuals think of suicide — not running toward death, but running away from a desolate life.
Understanding this provides an important key for suicide prevention: hope. A tiny amount is often enough.
It is my sincere wish that the information in this website will eventually provide many more resources – and hope – for those struggling with depression.
Conclusion & Action Steps
- There are several different surveys you can take to determine whether or not you have major depression. One is the Beck Depression Inventory. Complete this survey and, if you are experiencing depression, talk with a healthcare professional about the appropriate treatment steps.
- If you are struggling with these thoughts, tell someone now and get the help you need.6
- Sign up to be part of the email list.
1 Dr. Leanne Williams, a psychiatrist at Stanford University, is one of these researchers. Here is one of her recent articles describing abnormal brain activity in patients with depression and anxiety disorders:
Williams, L. M. (2016). Precision psychiatry: a neural circuit taxonomy for depression and anxiety. The Lancet Psychiatry, 3(5), 472-480.
2 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
3 Thapar, A., Collishaw, S., Pine, D. S., & Thapar, A. K. (2012). Depression in adolescence. The Lancet, 379(9820), 1056-1067.
4 Warga, J. (2016). My heart and other black holes. New York: Balzer Bray.
5 Márai, S. (2002). Embers. New York: A.A. Knopf.
6 Visit the National Suicide Prevention Lifeline at: https://suicidepreventionlifeline.org/
Dr. Pamela Coburn-Litvak has published research articles on exercise and stress in Neuroscience and Neurobiology of Learning and Behavior. Her latest book, Leaving the Shadowland of Stress, Anxiety, and Depression, was published in 2020.
After receiving a Ph.D. in Neurobiology and Behavior from the State University of New York at Stony Brook, she served as both Assistant Professor of Physiology & Pharmacology and Special Assistant to the Vice President for Research Affairs at Loma Linda University in Loma Linda, California. She then joined the Biology department at Andrews University and developed courses in human physiology as well as the neurobiology of mental illness. She also founded Rock @ Science LLC, a company that specializes in health and science education and web development. She co-developed the brain and body physiology segment of the Stress: Beyond Coping seminar with its creator, Dr. William “Skip” MacCarty, DMin.
Dr. Coburn-Litvak currently lives in California with her husband. Their two daughters are mostly grown and attending school elsewhere.
When she’s not studying or teaching about stress, she enjoys stress-relieving activities like puttering around the garden, taking nature walks with her family, knitting, cooking, and reading.
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