Decoding Depression: Signs, Symptoms, and Solutions

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For the next couple of posts, we’ll focus on “bread and butter” psychiatry concepts, taking a deep dive into common disorders such as major depressive disorder, generalized anxiety disorder, bipolar disorder, and more. The goal is to provide you with high-yield information about pathologies I see in practice and help differentiate normal day-to-day distress from issues best addressed by a mental health professional. Let’s dive into a discussion on major depressive disorder (MDD)!

What is MDD?

I think it’s fair to say we will all experience some degree of depression in our lives. Sometimes, life smacks us in the face, and we’re forced to activate our inner Eeyore. But how does the normal depression we’re familiar with differ from MDD?

In mental health spaces, we like to use the tried-and-true mnemonic MSIGECAPS to narrow down symptoms of depression. It stands for Mood, Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor Agitation/Retardation, and Suicide. Per the DSM, 5 out of these 9 symptoms need to be present for at least 2 weeks to diagnose MDD.

When I diagnose MDD, I like to start with a general screening centered around MSIGECAPS symptoms. What’s also very important is the degree to which these symptoms impact your day-to-day life – there must be significant impairment for a convincing diagnosis to be made. Another nuance that often gets overlooked is ruling out substances, medications, or other illnesses as potential causes of depressive symptoms. This requires a comprehensive medical review, often with additional lab work to ensure nothing is missed.

This is a good starting point, but it’s important to note that there are several subtypes of MDD, each with subtle differences in symptoms and treatment considerations.

Subtypes of MDD

MDD with Anxious Distress:

In this subtype, individuals present with 2 or more of the following symptoms during a major depressive episode (MDE): feeling tense or keyed up, feeling unusually restless, poor concentration due to excessive worry, fear that something awful will happen, or feeling as if you may lose control.

MDD with Mixed Features:

This subtype is tricky to diagnose as it can often be mistaken for bipolar disorder. Individuals present with 3 or more of the following symptoms during an MDE: elevated/expansive mood, grandiosity, more talkative/pressured speech, racing thoughts, increased energy/goal-directed activity, engaging in activities with potential for negative consequences (e.g., unrestrained spending, risky sexual practices), and decreased need for sleep. It’s important to note that if someone meets the criteria for mania or hypomania, a diagnosis of bipolar I or II disorder must be made.

MDD with Melancholic Features:

Symptoms of melancholia are likely what you think of when you imagine someone with severe depression requiring hospitalization. There are two criteria that must be met to satisfy this category. You must have one of the following during the most severe point of the MDE: complete loss of pleasure in all or nearly every activity or lack of mood reactivity (you still feel very depressed when experiencing positive things). Additionally, you must have 3 or more of the following: feelings of emptiness or despondency, worse depression in the morning, early morning awakening (2 or more hours earlier than your usual wake-up time), severe psychomotor agitation or retardation, significant weight loss/anorexia, or excessive guilt.

MDD with Atypical Features:

Atypical depression is elusive because it doesn’t follow the typical pattern of what we may think of as depression. Individuals present with mood reactivity (temporary lifting of depression when positive things happen) along with at least 2 of the following symptoms: significant weight gain/increase in appetite, excessive sleepiness, feeling of heaviness in the limbs (also known as leaden paralysis), or a pattern of interpersonal rejection sensitivity.

MDD with Psychotic Features:

Like melancholic depression, this subtype indicates more severe cases of depression. Individuals experience hallucinations and/or delusions exclusively during an MDE. These symptoms of psychosis can be congruent or incongruent with underlying mood symptoms. It’s crucial to establish a timeline of the mood and psychotic symptoms to ensure you aren’t dealing with a different disorder, such as schizoaffective disorder.

MDD with Catatonia:

Simply put, this subtype of MDD is diagnosed if features of catatonia develop during the depressive episode. I will discuss catatonia in more detail in a future post, as it can present in a wide range of illnesses.

MDD with Peripartum Onset:

Peripartum depression is similar to MDD. The difference is that symptoms appear during pregnancy or within 4 weeks of delivery. If symptoms start after 4 weeks, it’s considered run-of-the-mill MDD.

MDD with Seasonal Pattern:

This subtype was discussed in more detail in our previous post. It applies to recurrent MDD and is characterized by depressive symptoms following a seasonal pattern, typically more prominent in the fall/winter months. Symptoms disappear after these seasons, and over the past 2 years, distinctive MDEs with seasonal predominance have occurred without nonseasonal MDEs. Additionally, seasonal MDEs must outnumber nonseasonal MDEs over a lifetime.

When Should You Seek Treatment?

You may be wondering when to consider seeing a psychiatrist for treatment. For many, symptoms of depression don’t necessarily meet the criteria for MDD and resolve without much issue. However, I recommend coming in for an evaluation when you notice symptoms bleeding into your everyday life. Maybe you’re having trouble getting out of bed in the morning and prefer to sleep the day away despite other responsibilities. Perhaps you’ve lost your appetite or no longer enjoy food, or maybe you’ve lost interest in spending time with family and friends. These could all be signs of depression that warrant further evaluation.

With so many ways to approach and treat depression, having a good psychiatrist as part of your care team is essential. At Intempo Psychiatry, we understand that a one-size-fits-all approach simply doesn’t work. I tend to gravitate toward a combination of medication management and psychotherapy. This approach allows me to get to know my clients on a personal level and better cater treatment to their specific goals and needs. It also gives clients the opportunity to address maladaptive thought patterns that play into their depression. Addressing both pieces of the equation leads to better outcomes, and I aim to be as thorough as possible to help my clients return to their usual selves as quickly as possible.

Depression is common, and we all experience it at times. But when it starts to impact your life in profound ways, it may be time to check in with a mental health professional. With the right psychiatrist in your corner, you can find the best treatment and ultimately a more fulfilling life!

Until next time!

Dr. McCall