What to Expect With Major Depressive Disorder

Each person’s experience with major depressive disorder (MDD) is unique. Most experts view depression as a spectrum with no formal stages. Some people have mild symptoms that can be managed with lifestyle changes, like exercise. Others have severe depression that involves repeated episodes that greatly affect daily life and do not respond to medical treatment. Others’ experiences fall somewhere in between.^1-4

What is an MDD episode?

The main feature of MDD is a major depressive episode. These episodes are periods of 2 weeks or more in which a person has multiple symptoms of depression. These symptoms can greatly impact daily life. Examples of MDD symptoms include:^1,2,5

• Depressed mood
• Trouble concentrating
• Feeling worthless

The goal of MDD treatment is to end any current episodes and prevent new ones. Repeated major depressive episodes are called recurrences. Recurrence after the first episode occurs in as many as half of people with depression. The risk of recurrence increases with each episode of MDD they have.^1,3,5,6

The length of MDD episodes varies. People who are treated with antidepressant drugs may have symptoms for only 4 to 8 weeks. Without treatment, an episode can last 6 to 12 months or more.^1,5,6

Response versus remission

There is no cure for depression. But there are treatment options, like antidepressant drugs and talk therapy, that can help. A person is considered responsive to an antidepressant drug if their symptoms improve as a result of taking it.^6,7

Remission is possible, too. This is when a person’s symptoms improve so much that they do not test positive on screening tests for MDD. They are dealing with fewer issues for shorter periods of time.^6,7

Doctors look at response to treatment as a sliding scale:⁷

• No response: Less than 25 percent symptom improvement
• Partial response: 25 to 50 percent symptom improvement
• Response: Greater than 50 percent symptom improvement but not in full remission
• Remission: Would not be diagnosed with an active episode of MDD, and may even be back at baseline functioning

Some people have 1 or 2 spaced-out MDD episodes and then go into remission permanently. Others have short periods between episodes or never experience remission at all. Each person is different and requires their own individualized treatment plan.^1,2,6

It is possible to need antidepressant drugs for short periods and never need them again. But many people may need to take these drugs for longer periods of time or their whole life.^1,2,6

Finding the right treatment plan

Many antidepressant drugs are safe and effective in treating depression. However, they do not impact people equally. Some people will not respond to a drug at all, no matter the dose. Others may have a strong, positive response and go into remission quickly. The drugs’ side effects and their severity can vary greatly, too.^6,7

Finding the best treatment plan is often a trial-and-error process. It can take a long time. Most antidepressant drugs take weeks to start having an effect. Some drugs also have a wide range of possible doses.^1,6

A full trial of an antidepressant drug can last 6 weeks or more and include several dosage changes. The doctor will also start your dose small and increase it over time to minimize the risk of side effects. If symptoms are still not responding, the doctor may prescribe a new drug. A medication failing can be due to a lack of response or side effects that are too hard to tolerate.^1,6

Most people will need to try more than one antidepressant drug. You and your doctor will work together to determine what is safe and effective in your case. However, if you have tried multiple options and they have not improved your symptoms, you may have treatment-resistant depression.^1,5-8

Treatment-resistant depression

There are different definitions of treatment-resistant depression. Many experts think that having tried and not responded to 2 or more different antidepressant drugs qualifies as treatment-resistant depression. Estimates of how often this occurs vary widely. Anywhere from 30 to 70 percent of people with MDD are classified as having treatment-resistant depression.^3,7

Having treatment-resistant depression does not mean there are no options for symptom relief. Treatment planning just needs to be adjusted. A person may need to take multiple drugs at once. Brain stimulation like electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation (rTMS) are often used in these cases, too.^5,7,8

Also, there are newer drugs and treatment options currently being studied for treatment-resistant depression. Your doctor will not stop trying to find the best treatment plan until your symptoms are improving.^5,7,8

Predictors of worse outcomes

It can be impossible to predict a person’s long-term experience with MDD. But there are several factors that might increase the risk of worse outcomes from the condition. Poor outcomes may include having more severe symptoms, less response to treatment, or recurring MDD episodes.^1-3,7

Examples of risk factors for worse MDD outcomes include having a history of:^1-3,7

• Depression in family members
• Multiple MDD episodes (recurrences)
• Shorter time periods between episodes
• Childhood trauma or abuse
• MDD diagnosis at a very young or old age
• Other mental health health conditions, such as anxiety or obsessive-compulsive disorder (OCD)
• Other medical conditions, such as diabetes, heart disease, cancer, or stroke
• Needing to try multiple different antidepressant drugs due to lack of response
• Repeated exposure to stress
• Psychosis (hallucinations or delusions)
• Poor social support
• Not taking drugs as prescribed
• Hospitalization for MDD symptoms

Even if a person has several of these factors, they will not necessarily have poor long-term outcomes. Treatment planning and adjusting is an ongoing process, and new options are always being developed.^7,8

Complications and comorbidities

Complications are physical problems or behavioral changes that arise as a result of a medical condition. They may not be formal health diagnoses. The complications of MDD may include:^1,2,9,10

• Problems with employment
• Financial trouble
• Strained interpersonal relationships
• Use of substances like alcohol or drugs
• Thoughts of self-harm

Comorbidities are 2 or more diagnosed health conditions in the same person. They do not have to be diagnosed at the same time. Having depression may increase the risk of developing a health condition. Having another health condition also may increase the risk of developing depression. It is also possible for comorbidities to not be related.^1,2,9-11

The most common comorbidities that occur with depression include:^1,2,9-11

• Diabetes
• Heart disease
• Stroke
• Parkinson’s disease
• Arthritis
• Substance use disorder

You and your doctor will work together to figure out what conditions you are at risk for and how to monitor for them.

Suicide risk

Depression increases the risk of suicidal thoughts. As many as 2 out of every 3 people with MDD will have thoughts of harming themselves. How severe these thoughts are and the risk of self-harm vary between people. The risk of suicide is higher among those with MDD than among the general population.^1,2,5

If you are having thoughts of harming yourself or others, seek immediate help. You can call or text the Suicide and Crisis Lifeline at 988 anytime in the United States.¹²