Sure, you know Major Depressive Disorder (MDD) when you see it: at least two weeks of depressed mood or anhedonia, yada, yada, yada. But! There are many masks to MDD, each with their own treatment implications. Are you assessing for subtypes/specifiers? MDD is not MDD is not MDD. Specifier can be thought of a fancy way of saying “subtype.” It means the disorder’s presentation has a particular detail or details that make it unique under the MDD umbrella. Many disorders include specifiers, actually. While MDD specifiers include severity, remission and frequency, in this series we are concerned with matters of onset and symptom nuance of which there are 9 (count em, 9!). These include items like seasonal patterns and psychotic features.

The many faces of Major Depression bring with them interesting etiology and significant treatment implications. Much of what we do with depressed patients is similar (e.g., change the way they think to better how they feel.) However, how the MDD reveals itself can lead to additional intervention considerations. In the next 8 days well be reviewing these presentations and consider how they may influence the course of treatment.

Lets unmask the culprits

First, we need to look at Major Depression in general. According to the National Institute of Health (NIH), in 2017, 17.3 million US adults age 18+ experienced at least one episode of MDD. The Anxiety and Depression Association of America (ADAA) notes that MDD is the leading cause of disability in the United States for ages 15 to 44.

Depression is no stranger to history. To describe serious depression, the ancient Greeks used the term Melancholia, for “black bile” during a time when it was believed imbalances in bile influenced personality and mood. As psychopathology classification evolved, researchers realized other forms, like Atypical depression, where sufferers are able to experience some pleasure. Today, we recognize Melancholia and Atypical depression as subtypes of MDD, which we’ll explore later this week.

As research progressed, it came to be agreed upon that there are 9 common characteristics of serious depression. In the 1970s, this came to be known as Major Depressive Disorder. Today it is recognized in the Diagnostic and Statistical manual of Mental Disorders, 5th Edition (DSM-5) that people experiencing at least five of the following, lasting for a minimum of two weeks, qualify for an MDD diagnosis:

  1. Dysphoria, or unpleasant mood (sad/depressed/irritable)
  2. Anhdeonia, or an inability to experience pleasure
  3. Changes in sleep
  4. Changes in appetite
  5. Concentration problems
  6. Feelings of worthlessness, shame and guilt.
  7. Preoccupations of demise (thoughts about death, suicide, or even making suicide attempts)
  8. Lack of energy/motivation
  9. Psychomotor agitation or slowing

The above can be considered the “standard MDD presentation,” or the framework symptoms. It tends to be the presentation of MDD of people who become depressed in response to psychosocial stressors. However, a large percentage of depressed patients have clusters of MDD symptoms that take on unique presentations, some being severe enough to be caricaturist (e.g., not only being fatigued, but literally feeling held down by a weight). It is then recognized as a subtype of MDD. These presentations are generally believed to be inherited, or endogenous, meaning “occurring from within,” as opposed to reacting to a psychosocial problem.

As you will see over the next week, MDD specifiers and subtypes are quite varied. These variations are important to note because they could indicate, for example, we need to be extra vigilant for emerging Bipolar Disorder, or extra cautious of suicidal possibility.

Stay tuned for tomorrow’s post on Psychotic Features to kick off the specifiers.


American Depression and Anxiety Disorders Association. Understand the facts: depression. (2020, July 8).

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013

National Institute of Health. (2020, July 8). Major Depression.