Double Depression

Double depression occurs when two specific types of depression occur together and often goes undiagnosed and untreated. Here are the facts about this serious illness.

The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5) describes depressive disorders as a group of mental health disorders characterized by low (depressed) mood, and accompanied by some or all of a list of other symptoms, including:

• Loss of interest in most activities
• Changes in appetite
• Sleep disruptions
• Jittery movements or slowed movements
• Low energy and fatigue
• Feelings of guilt or worthlessness
• Reduced concentration
• Suicidality

One of the depressive disorders listed in the DSM-5 is persistent depressive disorder (PDD), also known as dysthymia. Persistent depressive disorder is, as the name suggests, a chronic, low-grade depression that lasts for at least two years.

Major depressive disorder (MDD) is, as its name implies, a more severe form of depression that involves most of the DSM-5 depressive symptoms. Double depression is a combination of these two specific types of depressive disorders.

What is Double Depression?

What is meant by the phrase “double depression?” This is the unofficial term for persistent depressive disorder that is complicated by one or more bouts of major depressive disorder.

Although persistent depressive disorder is generally a mild to moderate form of depressive illness, more than 75% of individuals with the condition have exacerbations where their depression symptoms worsen enough to meet the criteria for major depressive disorder. When this phenomenon occurs, it is informally referred to as “double depression.”

Difference Between Double Depression and Major Depression Without Dysthymia

The main difference between major depressive disorder without dysthymia and double depression is that people with double depression usually have more persistent depressive symptoms and are at a much higher risk for relapse once treated. As well, double depression has a higher rate of comorbidity (co-occurring mental health disorders) than major depressive disorder on its own.

Symptoms of Double Depression

Double depression symptoms are variable but are a mixture of the symptoms of MDD and PDD. Although there is a lot of overlap in the symptoms of these two depressive disorders, there are some key differences. The most common symptoms of persistent depressive disorder are feelings of hopelessness, worthlessness, low self-esteem and pessimism, while major depressive disorder symptoms tend to be more “neuro-vegetative,” such as sleep and appetite changes, loss of interest in activities and fatigue/low energy.

Double depression is characterized by chronic low-grade depression (PDD) punctuated by one or more episodes of worsening symptoms (MDD). When persistent depressive disorder becomes complicated by superimposed major depressive disorder, the feelings of hopelessness and low self-esteem typical of persistent depressive disorder tend to worsen considerably.

What Causes Double Depression?

Depressive illnesses are caused by a mixture of genetic and environmental factors. There are a number of genes in people’s DNA that can predispose them to depression and other mental health disorders. The number of these genes that a particular individual has will determine the likelihood that the individual will develop depression.

Environmental factors are the other factor in determining people’s likelihood of becoming depressed and include:

• Low socioeconomic status
• Lack of social support
• Female gender
• Major life changes
• Life stressors
• Previous history of trauma or abuse
• Substance use
• Lower education
• Unemployment
• Previous or current history of mental health disorders
• Family history of depression (partly due to genetics)

Depression’s physical basis is in brain chemical (neurochemical) abnormalities, as well as structural changes and abnormalities in the function of the brain. As such, depression is very much a physical illness, which explains why people can’t “just cheer up” and “get over it.” It also explains why many people get depressed when life is going well.

Diagnosing Double Depression

Double depression diagnosis gets missed in many cases because many affected people do not seek help. It is the nature of depression that people feel hopeless, worthless and lose interest in all activities. These are symptoms that deter people from taking the initiative to seek help.

As well, it is common that people with depression do not realize that there is anything medically wrong. They feel that their symptoms are simply “the blues” and they just need to get over it. This is especially true of persistent depressive disorder since symptoms are milder and more chronic; therefore, affected individuals often come to believe that feeling depressed is just “normal” for them. This is another significant deterrent to seeking treatment.

However, depression is very much a serious medical condition with serious consequences. Depression is the leading cause of disability worldwide and is a leading cause of suicide. Depression is treatable, and to go undiagnosed and untreated brings needless suffering and disability to those affected.

For people who do seek help, there is no specific blood test for diagnosing depression. Rather, diagnosis is made by identifying the diagnostic criteria from the DSM-5 by interview, usually aided by questionnaires.

There are currently no criteria for double depression in the DSM-5, so the diagnosis is made by identifying the criteria for MDD and PDD. Unfortunately, often only one of the two disorders is diagnosed in double depression because of the similarities in symptoms.

Feelings of depression or anxiety can lead to suicidal thinking. If you or a loved one is experiencing suicidal thoughts or tendencies, call the National Suicide Prevention Hotline at 1-800-273-8255.

Treatment for Double Depression

The mainstay of double depression treatment is medications with or without psychotherapy. The most studied and effective psychotherapy approach to depression is cognitive-behavioral therapy (CBT).

Double depression medication choices are the same as for either MDD or PDD alone. The usual first and most effective choice is a medication from the selective serotonin reuptake inhibitor (SSRI) class of drugs. However, genetic and physiological differences mean that different medications may be effective in different people, so a trial and error process may be required to find the right choice.

There is good evidence that healthy lifestyle choices and improvements in work-life balance can have significant positive effects on depression. This is why The Recovery Village uses recreational therapy as part of a comprehensive treatment program for individuals with mental health and co-occurring substance use disorders.

Even people whose double depression remains resistant to treatment should continue to work with their health care provider because there are more involved therapies that address treatment resistance.

Related Topic: High functioning depression treatment

Prognosis and Outlook

Double depression prognosis depends on a number of factors, including the severity of symptoms, the individuals’ genetic make-up and life situation and the particular therapy used during treatment. Response to therapy can be slow, as antidepressant medications often take between three and six weeks to have their full effect. Many people require dose adjustments or medication changes, which can add further delays to improvements. People who combine medications with CBT have a better prognosis.

Double depression is treatable and people with depression should work closely with their health care provider to achieve remission of their symptoms and a full return to good health and function.

The Recovery Village offers professional assessment and treatment programs for depression and co-occurring substance use disorders. Our trained professional staff has the expertise and experience needed for treating even complex cases. Please feel free to contact us for a confidential discussion with one of our representatives.

Editor – Megan Hull

Megan Hull is a content specialist who edits, writes and ideates content to help people find recovery. Read more

Medically Reviewed By – Dr. Andrew Proulx, MD

Andrew Proulx holds a Bachelor of Science in Chemistry, an MD from Queen's University, and has completed post-graduate studies in medicine. He practiced as a primary care physician from 2001 to 2016 in general practice and in the ER. Read more