Dr. Moses Appel (Edited by Matthew Shields)
What is Major Depressive Disorder, and How Can We Treat It?
“So, you’re telling me you’re sad?” asks Michael’s friend, Jerry. “Everyone gets sad sometimes. You just need to change your perspective.”
“No,” Michael snaps. I’m telling you; I can’t get out of bed in the morning. I barely sleep, and I can’t stop eating. I used to love reading, but now all I can do is binge YouTube shorts. I just want this pain to stop. Have you never felt this way before?”
Jerry pauses for a second. “I don’t think so,” he finally answers. Michael’s confession was deep, and he felt uncomfortable with it. What if Michael’s emotional pain is indicative of a serious problem? Jerry wonders.
Why are Michael and Jerry not understanding each other? How could they have communicated better?
Michael and Jerry aren’t bad guys; they just need better language to express themselves. Both Jerry and Michael misunderstand that Michael’s symptoms come from Depression. If they were both more aware of what is and isn’t Depression, their interaction would be entirely different.
What is Clinical Depression?
Depressive disorders are clinical mental health conditions typified by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities. Depression goes beyond the typical ups and downs of life and can significantly impact a person’s thoughts, behaviors, and emotions.
Unfortunately, Depression is a prevalent ailment. Seven percent of people will experience the disorder over their lifetime, while the population with the highest prevalence rates are 18-29-year-olds. Women are two times more likely to experience Depression than men; although more women attempt suicide, more men complete suicide.
In Psychology, we mainly focus on two types of Clinical Depression– Major Depressive Disorder and Persistent Depressive Disorder. Here, I’ll focus on the former.
DSM–5 defines a person as having Major Depressive Disorder if they experience five out of nine symptoms over a two-week period. If a symptom is typical for the individual or caused by other factors, like medical conditions, it doesn’t count toward the diagnosis. Additionally, one of the five symptoms must be a depressed mood or a loss of interest and pleasure (anhedonia). I’ll explain both below.
Here are the nine potential symptoms of Major Depressive Disorder:
1) A depressed mood, which is indicated either from a subjective report or observations made by others
2) Loss of interest or pleasure in customarily enjoyed activities
3) Experiencing significant variation in weight or appetite. For variations in weight, we define “significant” as having gained or lost five percent of one’s body weight within two weeks.
4) Insomnia (trouble sleeping) or Hypersomnia (sleeping too much)
5) Psychomotor agitation or retardation. Basically, being either overly agitated or overly lethargic.
6) Fatigue or loss of energy
7) Feelings of worthlessness or excessive or inappropriate guilt
8) Diminished ability to think, concentrate, or marked indecisiveness
9) Recurrent thoughts of death or suicidal ideation. This point warrants deeper inspection:
a) Recurrent thoughts of death (thinking about death a lot) are counted even without experiencing suicidal ideation.
b) Suicidal ideation can take a few different forms. There’s a distinction between passive and active suicidal ideation. Passive suicidal ideation is the thought of not wanting to be alive (i.e., “I wish I wouldn't wake up tomorrow),” while active suicidal ideation is where someone actively has thoughts to take their own life.
c) Within active suicidal ideation, we distinguish between having a plan (i.e., “I plan on taking my own life, and I’m going to it by…),” and not having a plan (i.e., “I don’t have a plan, but I’m considering doing something to take my own life).”
d) We also make sure to look for a history of suicidal attempts, as they’re one of the main predictors of future suicidal behavior.
Therapy Options for Major Depressive Disorder
In my practice, we utilize three primary approaches to treat Major Depressive Disorder. We often use a combination of them and choose between them with our clients. These are:
1) Behavioral Activation
2) Cognitive Behavioral Therapy (CBT)
3) Acceptance and Commitment Therapy (ACT)
Behavioral Activation Model
As we’ve mentioned earlier, when people experience Depression, they’re less likely to participate in activities. And when people are more inactive, they tend to feel more depressed. Unfortunately, this is a very tough cycle for people to handle. We utilize Behavioral Activation to break this loop.
Initially, people find it very hard to increase their activity level since they’re depressed and feel like they don’t have the initial jolt of energy or interest to be active. Nevertheless, once they start reengaging with life, they feel better, encouraging them to continue doing actions that make them feel better. For example, if one talks to a neighbor for a few minutes, and consequently their mood improves, that motivates them to undertake more healthy actions to upgrade their mood further. This progression sits in opposition to the cycle of inactivity leading to Depression– that leads to ever more inactivity.
When choosing activities for Behavioral Activation, it's essential to focus on two main criteria. First, select enjoyable activities, which encourage engagement and reward the decision to be active. Second, prioritize activities that have personal meaning to the individual. These can take many forms, but primarily, they’re activities that make the individual feel productive or give them a sense of mastery. I've discovered that a blend of these sorts of activities is particularly beneficial for clients dealing with Depression.
Cognitive Behavioral Therapy: CBT
The basic conceptualization of CBT is that what we think and do affects how we feel. Regarding Major Depressive Disorder, this model posits that our thoughts cause us to act in a certain way, which then determines how we feel emotionally.
While this model makes sense on the surface, the reality is far more intricate. Thoughts, emotions, behaviors, and bodily sensations are deeply interconnected, influencing one another in a continuous loop. For example, imagine someone believes that no one likes them. This thought alone can spiral into feelings of sadness and hopelessness, manifesting physically as fatigue and a sense of heaviness. In response, they might withdraw from activities that could lift their mood, instead spending the day mindlessly doom-scrolling while eating a family-sized bag of chips—further reinforcing their negative feelings and their sense of negative bodily sensations.
Do you see how interconnected each of these different factors is?
Cognitive-behavioral therapy addresses each of these factors (thoughts, emotions, behaviors, and bodily sensations) to improve people's mental states ultimately. Here is a bird's-eye view of some cognitive and behavioral skills. After displaying these, I'll delve more into Cognitive Restructuring.
1) Cognitive Restructuring
- This involves identifying cognitive distortions in order to then generate more accurate thoughts.
2) Behavioral Experiments
- This is where we actively challenge our thoughts and feelings by putting them to the test. If someone thinks that no one wants to talk to them,
maybe the move is for them to reach out to ten friends and ask them how
their day was. When they see that six out of ten responded, that proves
their initial assessment was wrong.
3) Behavioral Activation
- This is what we discussed before: getting up and actively doing things
instead of avoiding activities. As Nike puts it: "Just Do It."
Cognitive Restructuring
As I mentioned above, cognitive restructuring is a way to challenge cognitive distortions. Cognitive distortions are inaccurate ways of thinking. Common ones in Depression are:
a) All or nothing thinking– Viewing situations in extremes, with no middle ground. Sometimes called ‘black and white thinking.’ E.g., "If I'm not perfect, then I've failed;" "Either I do it right or not at all."
b) Over-generalizing– Making overly broad conclusions drawn from minimal evidence. “Today was a terrible day. Therefore, my whole life sucks” (even though yesterday was a great day.)
c) Mental Filter– Only noticing evidence that’s in line with previously held negative beliefs, such as noticing the bad grade on the math test and declaring oneself stupid, while ignoring other evidence that shows one’s intelligence.
d) Disqualifying the positive– This is very similar to the last point. Here, the problem is in discounting the good things that have happened or that one’s done. “My A+ on the History paper doesn’t count because it was so easy. I’m still stupid.”
e) Jumping to Conclusions– Imagining we know what others think or predicting the future. “I can just tell my daughter hates me. I’ll never be a good mom.”
f) Magnification & minimization. Magnification is blowing things out of proportion (catastrophizing), while minimization is inappropriately discounting facts to make them less important.
Now that we understand Cognitive Distortions, let’s delve into Cognitive Restructuring. This process involves identifying automatic thoughts—like “nobody likes me”—pinpointing the distortions driving those thoughts, such as all-or-nothing thinking or jumping to conclusions, and then replacing them with more balanced, rational responses. For example, instead of saying, “Nobody likes me,” a more accurate thought would be, “Some people like me, and some don’t.” The goal isn’t to sugarcoat reality but to develop a more truthful and constructive perspective.
Over time, practicing cognitive restructuring can transform the way we feel. Imagine the difference between thinking, “Everyone hates me,” versus, “Some people like me, and others don’t.” Even a minor shift in perspective—from feeling like a total failure (an F) to feeling okay (a C)—can be enough to inspire action, like engaging in behavioral activation. These small victories create a positive feedback loop, gradually improving mood and motivation. CBT’s strength lies in how its skills interconnect, each building on the other to foster meaningful change.
While CBT is a central approach to treating MDD, let’s briefly discuss another one: Acceptance and Commitment Therapy (ACT).
Acceptance and Commitment Therapy (ACT)
The goal of ACT is to gain psychological flexibility, and we do this by engaging with the “hexaflex” (presented in the graphic below). In treating Major Depressive Disorder, we first have the client explain what’s important to them. Let’s say they say “family.” Then, we ask what actions they must take to live according to this value. It might be spending more quality time with their parents, working more hours to support their family, or even going to the gym to be a better family member. Our goal is to have them take more actionable steps to live according to their values, which helps them feel better.
Here's the problem, though. Experiencing Depression is emotionally demanding. Getting out of bed in the morning is hard enough, and now we expect them to hit the gym! Where are they going to get the strength to do that?
Ultimately, ACT embraces each of the six points of the “hexaflex” to increase clients’ psychological flexibility. The hexaflex includes cognitive defusion, acceptance, values, committed action, ontact with the present moment, and self as context.
We utilize cognitive defusion to change our relationship with our thoughts. Here, we aim to create distance between who we are and what we’re thinking. After practicing cognitive defusion, our thoughts become less potent because they’re not as internalized. In “acceptance,” we accept and make space for our challenging feelings instead of fighting them.
For values, we guide our behavior based on our values instead of acting because of our thoughts or feelings. As we’ve seen, thoughts and emotions are not good representations of who we are; living according to our values allows us to become the people we want to be. Committed action, the sustained continuation of actions and behaviors rooted in our values, keeps us on track to achieve more psychological flexibility.
In “contact with the present moment,” we focus on the here and now instead of worrying about the future or the past. I could give an explanation here, but I’d be doing you a disfavor if I didn’t first quote Dr. Jon Kabat Zinn, one of the world leaders on Mindfulness. “What is the purpose of all this living if it's only to get some place else [like reliving past or anxiously plotting the future] …wait a minute, this is it. This is your life. We only have moments. This moment's as good as any other. It's perfect.” We can’t change our past and we certainly shouldn’t sacrifice the possibilities of the here and now to “live” in a future that doesn’t yet exist. When clients have trouble with ACT, so often it’s because they neglect the present moment.
Summary
1) Depression affects many people.
a. More women are affected than men.
b. Depression is most common in 18–29-year-olds.
2) Treatment options for Depression
a. Behavior Activation (“Just Do It.”).
b. CBT: Changing thoughts and actions to feel better.
c. ACT: Changing our relationship to the thoughts and feelings to make them less harmful and staying committed to acting in line with our values,
instead of letting our thoughts/emotions direct our behavior.
3) Reach out to a therapist!
a. Reaching out to a therapist can help individuals by creating thought-out
solutions to specific situations.
Disclaimer: All characters and scenarios in this post are entirely fictional. This content is intended for informational purposes only and is not a substitute for professional therapy or treatment from a licensed mental health provider. To contact Dr. Appel, please email office@ADOPsychologyCenter.com.