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The Development and Course of Major Depressive Disorder

Rashmi Nemade, Ph.D., edited by Kathryn Patricelli, MA

It is now understood that major depressive disorder (MDD) can first occur at any age. Most of the time it appears more noticeably at the start of puberty. The highest rate occurs with people in their 20s, but it is not uncommon for people to experience depression later in life. The course of MDD differs widely. It can last for short periods of time with mild symptoms or long periods of time with severe symptoms, and any variation in between. Typically, clinicians try to figure out how long a person has had symptoms. The longer and more severe the symptoms, the more chances of there being a personality, anxiety, or substance use problem that may be causing or contributing to the depressive symptoms. Recovery is variable as well. If an individual has been depressed for only a few months, they can often recover quickly. However, if a person has severe symptoms, has been depressed for several months to years, or has another condition, such as an anxiety or personality disorder, then recovery may take much longer.

depressed childHow often one experiences MDD depends on how long they feel depressed and the severity of their symptoms. If someone only feels depressed for a month or so every few years, they probably won't experience MDD very often. The risk for recurring depression is higher in individuals who have had severe, crippling episodes. It is important to note that MDD, particularly with psychotic features, such as hallucinations or delusions, can also transition into schizophrenia.

More women experience MDD than men. However, there are no differences in the age it first occurs, the course, or response to treatment between the genders. The likelihood of suicide goes down the older the person gets, but the course and recovery of MDD does not change with aging.

There are risk factors that can lead people to develop MDD such as temperament, environment, or genetics. Temperament is the combination of mental, physical, and emotional features of a person (their personality). People who have a negative outlook on life or temperament have a natural tendency to develop MDD in response to stressful life events. Stressful events are environmental risk factors that can trigger MDD. These may include the death of a loved one or other major losses such as losing a job or going through a separation or divorce. Other life changes may trigger depression as well. Even normal developmental milestones such as puberty, marriage, or retirement may trigger depression when a particular event is personally distressing to a particular person. For example, a person who loved their job may become depressed after they retire. These stressful situations may be recent, or they may be past events that are strongly remembered for some reason. For example, thinking deeply about stressful past experiences such as emotional, physical, or sexual abuse can trigger an onset of depression. Individuals with Post-Traumatic Stress Disorder (PTSD), who have experienced a traumatic event such as military battle, rape, severe automobile accident or natural disaster are more likely to suffer from depression than people who have not experienced such trauma. When there are multiple and different negative childhood experiences, there is a higher tendency to develop MDD. Major depressive disorder also has runs in families. People who have a parent, brother or sister with major depressive disorder are 2-4 times more likely to develop the disorder themselves than those in the general population. Approximately, 40% of those with MDD have a genetic link to the disorder.

There are also disorders or medical conditions that can increase the risk for developing MDD or making it worse. Examples include substance use, anxiety disorders, and borderline personality disorder. In these situations, treatment and recovery depends on finding the true cause of MDD. Long-term or crippling medical conditions such as diabetes, morbid obesity and heart disease are also risk factors for MDD. There is currently no lab test (such as a blood test or brain scan) that can confirm whether a person has MDD. However, some lab tests can appear different than normal during an active depressive episode. For example, differences in measurements of electrical activity in the brain during sleep have been found in 90% of people who are hospitalized for MDD. Even people with depression who do not have symptoms severe enough to require hospitalization often show these differences. Other differences in brain chemicals and hormones also occur with depression. At this time, none of these tests are reliable or specific enough to prove that the cause is major depressive disorder.

Even though lab tests aren't used to diagnose depression, doctors will often request them. These can be helpful in finding other conditions such as thyroid trouble, cancer, arthritis, and other diseases that might be causing the depressive symptoms. Later in this center, we will discuss more about how clinicians diagnose depression using lab tests, psychiatric interviews and self-report questionnaires. Symptoms of Major Depressive Disorder usually develop over a few days or weeks. Many people feel anxious or mildly depressed for a while before a full depressive episode becomes apparent. Often, the symptoms eventually disappear and functioning returns to normal. The DSM-5 provides labels that describe the course of a person's Major Depression:

  • "full remission" means there are no current depressive symptoms
  • "partial remission" means that the person currently has fewer than five depressive symptoms or has had no symptoms at all for less than two months;
  • "chronic" means that a person has met all of the diagnostic criteria for Major Depressive Disorder for two or more years.

Approximately 20-30% of people with Major Depressive Disorder experience partial remission of symptoms, while 5-10% of people have chronic MDD.

Suicide is a risk during times of MDD episodes. Women have a higher risk of suicide attempts, but their risk for being successful is lower. This is because they often choose methods such as an overdose rather than use of a gun. A history of suicide attempts or threats greatly increases the risk of a successful suicide attempt, but it is important to note that most completed suicides are done by those who have never attempted it before.


Reader Comments

depressed - Penney Comstock - Mar 13th 2013

I am so depressed!! A day doeasnt go by with out me wanting to end my life!! I have lost interest in dooing anything at all. I cant seem to keep a job for more than a couple years!!. I was a major drug attick for years but that stopped 25 years ago..I can honastly say!! My grandchildren are thew only thing in this world that make me happy but I dont even go see then a soften as I want to because I am happiest sitting on my couch watching reruns and eating junk, I have gained 15 lbs in the last 2 months!! I Hate life

Hang in there and be strong - - Feb 27th 2013

SEVERE mental illness needs to be treated by a professional.  In reading some of these comments, I feel healthy.  Psychosis is serious and if it is affecting others, I hope you get help.  We all hate ourselves at times and life always gets better.  Work things out with the help of medicine and professional help till time passes and you are physically and mentally stronger.

DON'T GIVE UP - - Apr 4th 2011

There is help out there.  One great group is TWLOHA (To write love on her arms)  Its a group that helps those that suffer from depression.  I just lost my 14 yr old niece to suicide and I have become very active in this group as well as my college daughter.  This is a very important step to getting the help you need.  You must talk about it and seek help.  I am so sorry for what you are going through, and I never thought I would go through this in my life time.  It has changed us forever, but I am determined tohelp others.  Please look them up.  I wish you the best.    

Mistakes with Pain - ArcAngel - Mar 18th 2010

I read alot of these comments and thought I should shure some thoughts.

Yes, Depression really hurts and hurts bad at times. I lost a friend from work whom killed himself after asking me if I can talk to him and see hium that night. Which I couldn't cause I was heading to the airport to pick up my wife. That same night he hanged himself. This really hurted me alot and I felt guilty for it and I never forgave myself for it.

Couple of years later a other good friend of my's was killed in a robbery and was shot 2 times while he was running to his store. This also affected me cause, well I am a cop and I always told his wife not to open the door to the store no matter what happens outside if there is a robbery, just call 911 and hide. Which that same day she did and didn't open the door, my buddy was killed at the door. And she saw very the gun man gun down her husband. Later that night she blame me for listening to me. She thought that if she would of open the door her husband, my buddy would be alive. Maybe that will be true but maybe the gunman would of went in and alos killed her. He left 2 kids behind and one of them had his 10th birthday 2 days after his father was killed. And when he was told he didn't react nor did he cry. Only when he saw me and ran towards me and jump on me and said that if I was with his dad that this wouldn't happen. Then he ask, "if I was his best friend now ?" And If I could spent his birthday with him. All this while he was cry and I was holding him tight. I wanted to die right then. I promise that I will. Which was the following day.

On the following day my wife and 2 daughters, 7 and 11 were going to go shopping and I ask my wife to return before 4:00pm that day cause I wanted to spend the rest of the day with my buddy kid. My wife left at about 11:00am and didn't return after about 8:30pm and with a stupid attuide. I was angry and I told her to get in the truck. I was thinking of heading to my friends house. On the way wife was fighting with me about the her shopping and the ice cream, that she needed to put those stuff away. Then we started to have some words and I told her I didn't want to argue cause I just wanted to get to his house when she {She is under alot of pressure also she lost her job, and I haven't yet get my retirement. So money is tight} But then she said something about my friend family and some thing about me taking on the guilt and now I think I need to take the family under my wings also, and I couldn't do this one right yet. I lost it. Damit I did, After about 1 or 2 slaps. I regain myself after hearing my girls crying. I stop the truck and I took a U-turn to head back home. I knew at that time that what I did was very wrong and that I wouldn't stand for any other person to hit my daughters no matter what has happen. So we got got home and we all cry and I ask for forgiviness and I gave the phone to my wife to make the call to the police, I left to the small hill with my girls next to my house and we cried and again I explain I was under alot of stress and I was dead wrong for doing what I did. My wife never did call. We slept together and talk all night long, we cried, hug, and ask for forgiviness and planned to go out the next day for a road trip with our girls.

 But the next day my wife sister wanted her to do her a favor after my wife drop off the girls from school. And my wife told her that the girls are not going to school cause we are taking the day for ourselves cause of what happen. My wife sister then called the Police and reported it. I was still sleeping with my girls when they got to my house and they had to come in force cause of my training.

To make a long story short, now I was alone at home without my two little leading ladies and my wife. I am under house arrest until the hearing and I am going crazy here at home without my family. After about 2 weeks waiting here I get a latter from my wife lawyers that she wants a divorce. All this mistakes has cause me great pain and loniness which I can't see the light at the end of the tunnel. When I do have permission to leave the house I tried to get help at the Church, I tried talking to people. My neighbors have really help for the most part and they all understand what happen. I do have my dad, dad, and sister support. But I can't explain I still feel alone. I want my girls and want to redeem  myself only if I can get one more chance. I know that I can. I am losing this battle with this pain that very day is building up. I am trying to keep busy and trying to get some chores done at home when I found out about the divorce. Now I don't want to do any thing alround the house only the garden cause my little Girl DJ ask me to keep it clean. I haven't seen my girls in over 3 weeks and I haven't spoken to them in about 1 week. I understand what I did was wrong but cause of my training I am judge more hardly. Why can't I see my girls. I can hear them at night. Thrusday. Friday, Saturday, and Sundays are the worse for me. 

I need them so dam much. And also my wife. I was wrong but not to be punished like this. All the pressure is getting to me. When I tried to get some sleep all I can do is cry and think. Regret of all my mistake and feel the pain it has cause me. I know physical pain queit well. But this pain is unbearable. The loniness, the guilt, the anger, the sorrow, the lost, the unknown, and the hate all built into a soup of this.....PAIN.

I want my girls back, I need an other chance. I want hope for tomorrow but I can't seem to get back on my feet. Has a boxer you are in the ring by yourself. But you have a corner that supports you and advice you, and take care of your wounds. I have God, in my corner. But yet my faith is weak at times. I long for a HUG...Damit I do. my life was full of hugs and kisses. Now I am cold and bitter. So many stuff that goes thou my mind that are bad I can't control them at times. I tried to do the worst once. Only a picture of my girls stop me. Thinking of the pain it will cause them for the rest of thier lives.

My dream was being that Dad there for them 24/7. I use to wake them up and put them to sleep {well bugging them, and playing with them} God, I really mess up.  

Wow, sorry for the spam, but it help me to get some things off my chest. At the time I started typing this I was crying and now I am not so I think it help for a while at least. if you read this keep in mind about the mistakes I made and the pain I cause to others and myself. I know I don't have all the fault but the cross is my's to bear only. No matter what took me to the edge.

Killing yourself is wrong which there is no return. After a mistake, and feeling the over welming pain, One tend's to think about giving up. Stand your ground. Think about your family and how you can rebuildand redeem yourself. Yea, I know it's stupid hard. Try to get a good corner which will support you. And Fight a good fight!   

Dont give up!!! - - Jan 8th 2010

Don't give up!!! There are people who care. Find yourself, love yourself and once you find that you will start viewing things differently.  It's not easy but possible.  My prays are with you....

You Are So Right (no hope, no help) - - Nov 2nd 2009

I read some of these comments, and apparently, I am not in this roller-coaster called life by myself. I also have tried to get help for my depression, but the Psychiatrist thinks I have a personality disorder, not depression, so he won't medically treat me. I feel nobody is listening to me. I know I'm depressed and the Psychiatrist thinks once a month visit with the therapist is what I need. I asked, what about the days between our visits, I'm on my own.  It seems that only individuals who are going through this understand.  Maybe, we should start counseling each other.  I don't know what the answer is, 'cause I believe that there's no professional help anyway.




All in my head... - Lizz - Oct 30th 2009

I've been suffering from night terrors, sleep disruptions and depression for as long as I can remember. I'm 18 now and no matter how many doctors, and psychologists I see they keep telling me its in my head. The sleep disruptions have been affecting my schooling and work life. I just feel so paranoid and tired all the time, there is nothing that can comfort me. Every time I try to see what they can do they imply that I have Hypochondriasis. That is certainly not the case as it has been proven that I am in poor health. They seem to only address my physical pain never the mental. Is there anything I can do?

NO SUPPORT = NO HELP = NO HOPE - KC - Oct 1st 2009

All I know is that I've suffered from severe deppression/anxiety for a very long time. I just turned 31 and I feel as if I've been suffering from this my entire life. Been hospitalized several times. Been on almost every type of anti depressant there is. Seen several of psychologists and psychiatrists over the years and still I have not gotten any better, only worst.  I've tried to get help from churches and pastors and no one can or will help me. I have no family and the friends I had, I cut off because I felt like no one can understand how I feel all they can do is criticize me. I cannot account for how many times I've attempted suicide and have not been successful. The only reason why I am still breathing is because I have a 10 yr old daughter who have no one in this world but me and I have no one in this world but her. You would think that would be enough to get better and to want to continue living.

Life can become so overwhelming that the most important person in one's life might not be enough for one to continue. I always felt like no one in the world could understand how I feel. By reading other people comments, I'm starting to think maybe someone else in the world just might understand.

If I have no support and no one will help me through this how can I have hope that one day I'll be okay?


empty - devan - Sep 22nd 2009

do u ever tour to hell ?

do u ever swim in blood sea ?

do u ever see a wacther(inside) ?

u all guyz juz feel n think datz crazy sick person's unnormal fo u, isnt it  ?! in d fack we're not crazy juz uniQ . .

LIFE IS HELL - - May 16th 2009

help me i feel like a body without a soul like a caged black bird,i feel like a zombie or a  lost ghost, help, its feels like ur dying many times a day, its like a hole the more you want to come out of it the more u sink in it,this what is called depression and only ones who really experienced it will agree with me.

Suicide: the easy way out???? - Freak Anomaly - Mar 17th 2009

I've been depressed numerous times, for various reasons, and i know i'm not out of the woods yet. but hopefully i'm getting there. I just flicked on to this site and read some of the comments and there was a remark about living being hard and suicide being the 'easy way out'.

Anyway, what i wanted to say was back when i was in the deep dark pits and i considered suicide i never once thought it was easy. Even though you feel your life is really hard and you don't want to go on, it's not easy considering death as your only option. i kept thinking to myself 'if i get hit by a bus today and die, that would be great' but whenever i actually considered doing the deed myself . . . all i could think about was 'what if i'm not successful?' then my parents would suddenly know what i was prepared to do and they'd keep bugging me and making me feel guilty etc and i didn't want that. I hated feeling alone and in pain but i didn't want a big fuss and loads of attention.

I've always thought that suicide takes guts but maybe that's just me. Staying alive . . . that takes guts too and i know for a long while i was practically dead anyway. I'm not saying that suicide is more difficult than life because life is tough, no doubt about it. i'm just saying that people put emphasis on suicide being the easy way out when i don't think it is. in all honesty, i'm not sure there is an easy way out of being depressed. I know suicide is 'giving up' whereas life is 'fighting' or whatever but i doesn't make suicide the easy way out. for instance, sometimes with me, thinking of all the ways i could die that day were sometimes all that got me through. the idea that it could all be over any minute . . . it's sounds odd but it kind of gave me hope. hope that if i could just make it through the next minute then i wouldn't have to fight anymore. i don't think that suicide is giving up. it's just where you want peace and stuff. you're tired and you need to rest. 

Like i said, i don't feel out of the woods yet and its probably been around a year since my last really bad episode. i still have really low days or weeks and in that time i just feel totally hopeless. it's like people say that your teen years are meant to be the best of your life and that just makes me think that it can only go downhill from here. I think the only things that have pulled me through are my bestfriend, who's been down the depression road herself, and dreams of travelling the world and seeing amazing things. I have some other dreams too and sometimes closing my eyes and drifting off into a day dream about them are all i can do not to get pulled under by depression. some of them i know will never come true and it hurts to know that but they are a useful tool to just stop or slow the bad descent into a black hole because at that point you don't care that they'll never come true. You just cling to any hope you can get.

I don't have any advice or anything. i wish i did but i don't. i just really wanted to make that point about suicide not being the easy way out. because it's not. life or suicide. When those are your options, there simply isn't an easy way.

Dont Give up, Just stay and suffer????? - Pat - Jan 4th 2009

I have lived this way for so long and so far no improvement. No medication can help. Can't find a treatment that makes life bearable.  We have tried them all. I have refractory major depression,PTSD, anxiety and sleep disorder. Not one day of my life is enjoyable. how long?  Another 30 years? 

Suicide is not the easy way out, believe me I've had 3 serious attempts, twice I was very close to being sucessful. Very angry to wake up in ICU.  It goes against every natural instinct of human nature. So when a person gets to a point of making serious attempts and really wants to end their lives they are fighting human nature and its not a simple thing to do.

I can't believe that I am the only one out here with Refractory Depression,  how do the rest of you deal with this? Or feel about it?


Don't give up! - - Nov 19th 2008

Don't give up. You can make it. People care about you.

There is no hope ... for myself that is - Michael - Sep 20th 2008

Years a decade now. bottled up . cannot understand how I have manage to survive until now. I am without any douby friends with death more than with those of life. Oh sure they say ittakes guts to live and its easy t commit suicide and suicide accomplishes nothing. The first may be true but the second most certainly is not. There is help out there... well no for many incl myself the help has only made things worse... I will accomplish the ceasation of suffering soon. For those of you will some doubt .. what can I say but follow up on it and seek pro help. It may help you get well. michael

help not understanding - - Jul 5th 2008

When your son's wife goes through her delusional states, how do you deal with that. How does he cope and make the realationship work?. Its hard with kids and trying to help this person cope with their deprssion, nothing ever pleases them. their helplessness makes you feel helpless.

About feeling helpless - - Feb 27th 2008
I just read what someone wrote and I really wish I could personally help.  My son's wife is undergoing a serious episode with depression.  I have seen first-hand two of these in her.  She gets delusional and thinks everybody wants to hurt her and she doesnt know why.  She doesnt react in front of her children and the 2 year old is showing knowlwdge that something is wrong with disruptive behavior.  NOw, I want to make something clear.  God doesnt give anybody this to cope with.  These are ideas that must be given up.  How we react to life's stresses is our own business.  Some can, others can not, but we are not left alone.  People dwell on their vague thoughts and ideas about Jesus, and they dont go to a gospel preaching church and really explore the Word of God, You see, if you dont get serious about Jesus, you will always be the victim of yourself and your environment.  Jesus is the Lord, and in Him you can overcome all things.  Jesus is your empowerment over all that drains your joy.  He is Life and Liberty over strife.  he came to set the captives free.  We are getting together to support and  pray for Jennifer, and we have faith that she will overcome.  Take your medications, go to therapy, and follow the Master's footsteps, seek Jesus.  This may be the missing element in your recovery!  God bless!

Can't believe my diagnosis but have to - LK P Panda bear - Feb 21st 2008

 Fustrated with my label is Bipolar II, I can relate to insomia  feelings of hopelessness, helplessness, can't sleep, can control my mood when I'm blue, most fustrating is sleep and tiredness, .  But I have never had psycotic delusions or hallucinations with this, either did my Dad who was Bipolar I  he had extreme mood swing from    manic to really low.  Mine seems to cycle with anxiety as more prevalent and anxiety over not being able to control my tiredness and mood and sleep.  But never lost control over my behavior of spending, sex or dangerous risky behaviior.    My  only fear is living like this and continuing to have to live feeling this way.  Ionly entertained wanting to end it because it seems like quality of life gets zapped away and drains all your energy just to cope.  This is depressing no wonder wer feel socially rejected, noone wants to be around us either.  Because it so DEPRESSING< and theere is'nt a dam thing they can do or you can do except hope    that the pill the Dr gives you will work. and that is the only hope you have.  And there is prayer if you believe but even that drains you.  BEcause you wonder in the amidst of this Where is He why did he give you this to deal with???   I know my family rejected my Dad I did I hated his disease and now I hat e myself because I have it too in some milder form.   I'm so scared to get my family triggered over this.  I have a loving husband and I have that onw thing to be thankful, but that doe'snt mean I livei in constant worry if this will wear him out too?  I just got a clear diagnosis this week, so this is al so frresh but expains my fatigue when all along i know  I was suffering Chronic fatigue sydrome, with anxiety and depression overlaying this.