All About Double Depression

Although the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) doesn‘t recognize the term “double depression,“ it does recognize the two diagnoses that make up double depression: persistent depressive disorder (PDD) and major depressive disorder (MDD).

Double depression happens when someone with PDD also meets the diagnostic criteria for MDD. If you live with PDD, chances are you’ll experience double depression at some point — in fact, up to 3 in 4 people with PDD will also experience MDD in their lifetime.

Persistent depressive disorder (PDD)

PDD used to be called dysthymia or dysthymic disorder. Some people also know it as high-functioning depression.

What sets PDD apart from other types of depression is its duration — PDD is a chronic, or long-term, form of depression. People who fit the criteria for diagnosis will have experienced symptoms consistently for at least 2 years.

In addition to a depressed mood, symptoms of PDD include:

• eating more or less than usual
• fatigue and sleep problems
• feelings of hopelessness
• difficulty concentrating
• low self-esteem

Major depressive disorder (MDD)

MDD shares many symptoms with PDD, such as having a depressed mood and experiencing a loss of pleasure in activities you used to enjoy. But for an MDD diagnosis to apply, symptoms will be present for at least 2 weeks, and they tend to be more severe than symptoms of PDD.

Other symptoms of MDD include:

• weight loss or gain
• loss of energy
• strong feelings of guilt or worthlessness
• moving more restlessly or slowly than usual
• trouble thinking or making decisions
• thoughts of death or suicide

Double depression tends to be more severe than other forms of depression because you’re experiencing symptoms of two different, overlapping conditions.

Research from 2015 found that people with double depression had the most severe symptoms of any group with a depressive disorder.

The same research also found higher rates of suicidal thoughts in people with double depression — just over 1 in 2 people with double depression reported suicidal ideation, and the study considered people with double depression to also be at a higher risk of suicide attempts.

Research from 2018 suggests that people with double depression have a higher chance of developing heart disease than those with other depression diagnoses. Experts think this is because the longer-lasting PDD symptoms mixed with the severity of MDD can increase exposure to more of depression’s health impacts than either diagnosis on its own.

Researchers also found that people with double depression experienced more hopelessness than those with other types of depression, which could affect long-term health.

The same factors that cause PDD and MDD are at the root of what causes double depression, but experts still haven’t identified one clear cause.

According to the DSM-5, factors that might increase your chance of experiencing double depression include:

• Temperament. People with higher neuroticism (tendency toward low moods) are more likely to experience PDD.
• Early life. Childhood trauma or losing your parents in early life could increase your chances of experiencing depression.
• Brain differences. Your prefrontal cortex, amygdala, hippocampus, and other areas of the brain could play a role in whether you develop PDD.
• Family history. Having a first degree relative, like a biological parent, with depression can increase your chance of also having it.
• Other mental health conditions. Living with another mental health condition, such as an anxiety disorder, may increase your chance of developing depression.

The DSM-5 doesn‘t list any specific symptoms for double depression, but some signs you might be experiencing it include:

• sudden loss of pleasure or interest in your activities
• changes in your appetite that lead to weight loss or gain
• strong feelings of hopelessness, sadness, or emptiness
• more fatigue or lower energy than usual
• sleeping much more or less than usual
• new thoughts of death or suicide

If you live with a PDD diagnosis, suddenly experiencing more severe depressive symptoms could be a sign of double depression. But if you’ve never received a depression diagnosis before, it might be harder to tell if what you’re experiencing is double depression.

Double depression is two co-occurring conditions, so there‘s no formal way to diagnose it.

If you notice your depressive symptoms worsening, you can reach out to a healthcare or mental health professional, and they can screen you for both PDD and MDD.

Since double depression is MDD on top of PDD, it might be a good idea to let them know if you’ve received a PDD diagnosis in the past. But even if you’ve never had a PDD diagnosis, you could still meet the criteria for both PDD and MDD.

Research from 2020 suggests that double depression may be harder to treat than other forms of depression. Still, research on treating double depression is ongoing, and treatment recommendations will likely improve as researchers learn more about the condition.

Medication

Medications such as antidepressants are often used to help manage the symptoms of double depression.

A selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) may be prescribed. Some commonly used SSRIs and SNRIs are:

• sertraline (Zoloft)
• fluoxetine (Prozac)
• duloxetine (Cymbalta)
• venlafaxine (Effexor XR)

Other medications you might take for double depression include atypical antidepressants and tricyclic antidepressants (TCAs).

Therapy

Psychotherapy, or talk therapy, might be used alongside medication or other treatment approaches to help you manage double depression.

Cognitive behavioral therapy (CBT) is a common and effective therapy for many types of depression, but you have other therapy options, too.

If you’re already seeing a therapist to manage PDD, letting them know about any new symptoms could give them a heads-up to screen you for MDD and help you explore new ways to manage your symptoms, if necessary.

Brain stimulation

When depression doesn’t respond to other forms of treatment, certain types of brain stimulation have been shown to help, including electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS).

Research from 2018 suggests that deep brain stimulation could be beneficial for people living with forms of depression that are harder to treat, but further studies are needed.

Professional support is often an important part of managing depression symptoms, especially when they’re severe and difficult to treat. But you can take steps to manage those symptoms at home, too.

Ways to manage double depression at home include:

• Get the rest you need. If you’re more tired than usual, give yourself permission to take it easy — shaming yourself for something that’s out of your control probably won’t help ease your symptoms, anyway.
• Focus on fuel. It’s unlikely that any single food will banish your depression, but evaluating which food choices may best empower you to manage your symptoms is worth a try.
• Take some deep breaths. Some 2017 research found that people who practiced deep breathing exercises at home reduced their depression symptoms more significantly than people who received only standard care for depression.
• Add movement when you can. You probably won’t feel much like exercising in the traditional sense if you’re experiencing double depression, and that’s OK. Physical activity is still an effective option for people with moderate and severe depression, and even gentle movement like walking or stretching could help.

Dealing with MDD on top of PDD can feel like a lot, but you don’t have to manage these symptoms alone. Double depression can mean more severe symptoms, so it’s important to reach out for help when you need it.

If you think you may have double depression and are looking for support, you can:

• connect with an online depression support group
• reach out to a licensed mental health professional
• check out these online resources for managing depression