Am I Depressed? Signs & Symptoms of Clinical Depression
*Disclaimer: This article is for informational & educational purposes only and is not direct medical advice. Please consult with your qualified professional clinician for medical advice, diagnosis, and treatment.
“Normal Sadness” vs. Clinical Depression
Am I depressed? This is a common question that millions are asking themselves at this very moment. Before we dive into a description of the most common signs & symptoms of clinical depression, let’s first make a distinction between the normal range of sadness vs. clinical depression. We need to acknowledge the fact that as humans, we are emotional creatures. This is what makes life great, but can also lead to problems at times. Sadness is a normal part of our human experience, but if that sadness begins to become persistent & pervasive enough, begins to interfere with important domains of our life, and represents a marked change from your emotional baseline, that’s when it worth considering whether or not it has developed into a depressive disorder. Now, there are many types of depressive disorders, but this article will focus on the most common type, Major Depressive Disorder also known as “MDD” for short.
How is MDD diagnosed?
It may come as a disappointment to some, but the standard of care for diagnosing MDD is still comprised of a clinical interview utilizing the criteria from the Diagnostic & Statistical Manual of Mental Disorders 5th edition or DSM-5. By no means is the DSM-5 a perfect tool, but it is still considered the standard, research based guide to help identify a cluster of symptoms that may represent a psychiatric disorder.
But, what about lab tests? Biomarkers? SPECT imaging? Specialized EEGs? Although the holy grail of depressive diagnostics is to have an objective biomarker to diagnose MDD, this is not a reality at this time. Despite bold claims by certain clinics across the country, imaging techniques or EEGs are not considered proven or standard of care diagnostic tools to diagnose MDD and have yet to be proven in large scale, well controlled studies. So, I advise the public to save your money and not shell out hundreds or thousands of dollars for these tests and procedures at this time. The old, tried & true clinician-patient relationship is still the standard.
MDD Criteria
Per the DSM-5, in order to meet the criteria for MDD, you must meet the following criteria for a Major Depressive Episode:
Experience at least 5 of the 9 symptoms outlined below, and at least one of the symptoms must be depressed mood or loss of interest
The symptoms must last at least 2 weeks or longer
The symptoms must represent a clear change from one’s usual baseline emotional state
The symptoms must cause impairment or dysfunction in an important area of your life ie school, work, personal life.
And to remember that MDD is a diagnosis of exclusion, meaning, technically one needs to rule out other medical, substance related, or other potential psychiatric causes of depression.
So, before we dive into each symptom one by one. Remember these themes: how persistent & severe is the symptom and does it represent a change from your baseline? Now, let’s go through each symptom in detail, one by one, with pertinent questions you should be asking yourself. If you prefer watching a video explanation of the signs & symptoms of MDD rather than reading, please check out my detailed YouTube video on this topic.
Symptom #1: Depressed Mood
As straightforward as this symptom may sound, a number of patients will respond to a question of “Have you been feeling depressed lately?”, with “What does that mean? What is depressed?”. Everyone tends to have their own interpretation, but in general this is referring to whether you are feeling sad, blue, down, or not as happy as usual. The depressed mood should be present for most of the day and for most days of the week. For some individuals and demographics, like children & teens, sometimes this symptom may not come out as classic sadness, but rather irritability or increased anger.
But, it’s not just as simple as whether a depressed mood is present or absent. One should consider the ability for this depressed mood to lift in light of positive, encouraging, or typically pleasant events. Can you experience a lift in your mood or not? If so, how long did that last for? And did you have to put forth any extra effort in order to experience that lift?
You should also consider whether your outward appearance & behavior have appeared more depressed. Whether from catching a glimpse of yourself in the mirror or from observations of others, have you:
Been smiling or laughing less frequently? Or is it not occurring as naturally? Do you have to fake it for the sake of keeping up appearances?
Do your facial expressions seem less bright or animated? Do they appear flatter, more blunted, or dejected?
Are you receiving comments from others asking, “Are you okay? , “What’s wrong"?” “You look kind of down".
Symptom #2: Decreased Interest or Pleasure
To be clear, this symptom is not necessarily about your motivation or follow through with actual activities, but focusing on the actual interest level itself. Whether you are participating in them or not, are you noticing a decreased interest in your usual activities or hobbies that typically bring you happiness or joy. And if so, how much of a decrease in interest are you noticing? If you still participate in these activities, how much pleasure, joy, satisfaction are you deriving from them? Is anything making you happy anymore?
This decrease in interest and pleasure is a theme that also extends into your current relationships. Are you noticing that you feel more emotionally disconnected or detached from acquaintances, friends, family members or your significant other? You may notice:
A decreased interest in what’s happening in their lives.
Although cognitively knowing you love or care for them, you may not feel that emotionally.
You may be isolating yourself from these relationships and avoiding contact with them.
You may feel numb and feel nothing at all towards these relationships.
And on that topic, a more extreme form of decreased interest or pleasure can be experienced as emotional numbness. This is often times misinterpreted as “not being able to feel happy”. But, more accurately, this is describing a difficulty in accessing the spectrum of your emotions. You may not be feeling as angry as you should be when someone pisses you off. You may not be as sad as you should be in a depressing situation. This experience can range from feeling like your emotions are blunted to literally feeling nothing. Feeling complete emotional numbness.
Symptom #3: Changes in your Sleep Pattern
This symptom cluster includes both hypersomnia and insomnia. It’s crucial for you to think about a time period, when you were not depressed, and try your best to remember, how many hours of sleep was I getting on average per night? What was my quality of sleep back then?
Hypersomnia is when you are sleeping too much and more than your typical amount of sleep when you are feeling well. Insomnia is comprised of:
Difficulties falling asleep at the beginning of the night
Difficulties staying asleep and experiencing middle of the night awakenings.
Waking up earlier than intended and having troubles falling back asleep in the mornings.
You should be factoring in, how many hours of sleep am I getting, what is the quality of my sleep itself, and how does this compare to my typical sleep when I am not depressed.
Symptom #4: Changes in Weight or Appetite
In the context of your depression, have you experienced a notable change in weight in a relatively short span of time? For example, an increase or decrease of 5% or more in the span of a month, while feeling depressed.
Even if there has not been an actual change in your weight itself, consider if you have noticed a change in your appetite or interest in food. Have you been eating more than usual or utilizing food as a means to cope with your sadness? Is your appetite decreased, compared to your usual self? And if so, consider the following:
How decreased is your appetite or interest in food? Do you have any appetite at all?
Do you feel as if you are urging or forcing yourself to eat?
Do others have to remind, urge, or force you to eat?
Also factor in the taste of the food itself. Do you feel that food is just not as enjoyable as it used to be? Do you feel that your favorite foods taste blander or like cardboard? Do you feel you’re just eating for the sake of calories & nutrition at this point. Is the food you’re eating literally tasteless to you?
Symptom #5: Fatigue
This symptom is a feeling of a loss of energy, feeling more tired than usual, or sluggishness. It’s important to consider how this fatigue relates to your functioning in respect to starting and completing tasks.
It may be more difficult to start daily activities, work or school projects, household chores.
It may be more challenging to start basic activities of daily living: showering, brushing your teeth, getting dressed, meal prepping.
Once you get started with a task, it still may be more challenging to push through & complete it.
You may actually not end up completing some or most of your usual tasks or ask for help for things you’d typically take care of on your own.
You feel like laying in bed all day.
Symptom #6: Psychomotor Slowing or Agitation
When it comes to psychomotor slowing, many people describe this as if their limbs are heavier than usual or that they are moving in molasses. You may be slower to respond in conversations, the rate of your speech itself may be slowed, or you feel like you’re moving slower than usual when completing tasks.
You may also experience the opposite. You or others may be noticing that you seem on edge, keyed up, tense, and have an unhealthy, restless energy about you.
Although not an explicitly listed or required symptom for the diagnosis of MDD, I also want to mention the symptoms of anxiety and panic in this section, as I find that these symptoms tend to go hand in hand with clinical depression. Consider if you have experienced the following:
Excessive worry or anxiety, beyond your normal day to day worries
Feelings of dread or that something terrible is about to or going to happen
Feelings of panic or actual panic attacks
Also consider, how long on average can you make it through a day without experiencing anxiety or panic. Minutes, hours, a whole day?
How much distress do you experience from the anxiety & panic feelings?
How difficult or easy is it for you to deal with these symptoms in order for them to subside?
Symptom #7: Feelings of Worthlessness or Guilt
We all struggle, to some degree, with internal self-criticisms. Whether we want to admit it or not, we all have an internal voice that likes to be a harsh critic. When we make a silly mistake, it says, “That was stupid of me. How could I be so dumb?”. But, imagine when you become clinically depressed, the intensity of those self-criticisms becoming significantly amplified. For example, those internal self-criticism may now become, “I’m a total failure. I am worthless. I am useless. I am pathetic.” Again, it’s possible you may have some of these thoughts even when not depressed, but in that case, ask if they have become more frequent or severe in nature.
In addition to the above, feelings of inappropriate or excessive guilt may occur for things you may or may not have even done. The focus of your guilt may be focused on actions from the past or perceived shortcomings in the present. The guilt may be about the fact that you are depressed itself or that you feel like you are burdening others with your struggles. These feelings of guilt can sometime reach delusional proportions. So what does that mean? A delusion, is a fixed, false belief in something that is not based in reality. This is considered a psychotic symptom. Now, to be clear, MDD with psychotic features is quite rare. And, when it does occur, the psychosis typically manifests as delusional thought content. If this is truly MDD with psychotic features, then this is not an indication of a permanent psychosis, but a temporary psychosis that will resolve once the clinical depression is appropriately treated. In some cases, both the psychosis and depression may need to be treated concurrently.
Symptom #8: Concentration Issues
This symptom encapsulates difficulties with:
Collecting your thoughts.
Planning out your day.
Your ability to absorb new or novel information.
Your ability to read things like books, websites, social media posts, text messages.
Your ability to sustain focus in conversations at home, in lectures, at work.
Are you noticing that you are spacing out and losing track during your favorite TV shows? Are you asking people to repeat themselves because you lost track of the conversation? Do you have to reread things over and over and still have a hard time understanding the content?
You should consider all of the above and determine if it has led to a decrease in efficiency, productivity or causing other problems in the various domains of your life.
Symptom #9: Suicidal Thoughts or Behaviors
This symptom area still remains somewhat difficult for both clinicians, loved ones, and those going through depression to discuss. But, it is a necessity to assess and can not be ignored. This is not as simple as a binary “yes” or “no” response to the question, “Are you feeling suicidal?”. One must consider the entire spectrum of the thoughts on death, dying, and suicide. Let’s work our way from one end of the spectrum to the other. Are you experiencing any of the following:
Thoughts of feeling tired of living. Feeling weary of life.
Being indifferent if you were to die. If I die in my sleep, or a car happens to hit me, so be it.
Thoughts that you are better off dead. Desires to die. Desires to kill yourself.
Coming up with a method of how you would kill yourself.
Coming up with specifics of how, when, where you plan to kill yourself.
Preparatory behaviors of suicide: getting your affairs in order, writing a suicide note, rehearsing a suicide attempt.
Attempting suicide:
Having an aborted attempt: where you started a suicide attempt, but stopped it yourself, partway through.
Having an interrupted attempt: where you started a suicide attempt, but someone interrupted you.
An unsuccessful attempt: where you went through with an attempt but survived.
A completed suicide attempt, leading to death.
Conclusion
Humans don’t neatly fit into symptom checklists and diagnostic categories. We as people and our life experiences are rich and complex. Some people will without a doubt meet the textbook criteria for MDD, where for others, after factoring in other confounding variables, it becomes quite murky.
So, to keep things simple, when considering the symptoms we have reviewed today, don’t forget the key questions of: does the constellation of symptoms represent a change from your baseline, are the symptoms persistent and severe, and are they impairing and important area of your life. I hope this article has helped educate you on the common symptoms & signs of MDD and how they may differ than our typical day to day sadness.
I hope you have found this overview educational & informative. If you have, please follow me on my YouTube channel or on social media @AndrewKimMD (Facebook, Twitter, Instagram)
Written By:
Andrew Kim M.D.
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*Disclosures: At the time of writing this article, Dr. Andrew Kim M.D. was an independent contractor on the Janssen Speakers Bureau and works as a Principal Investigator on FDA clinical trials for pharmaceutical sponsors.