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Major Depressive Disorder: Major Depressive Disorder

Major Depressive Disorder
Major Depressive Disorder

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table of contents
  1. Major Depressive Disorder
    1. Introduction
    2. Description of Major Depressive Disorder
      1. Differential Diagnosis
    3. Prevalence
    4. Assessment Strategies
      1. Center for Epidemiologic Studies Depression Scale
      2. Patient Health Questionnaire
      3. The Hospital Anxiety and Depression Scale
      4. Zung Self-Rating Depression Scale
      5. Beck Depression Inventory
      6. Hamilton Depression Rating Scale
      7. Quick Inventory of Depressive Symptomatology
      8. Montgomery-Åsberg Depression Rating Scale
      9. PROMIS Emotional Distress—Depression—Short Form
      10. Depression, Anxiety, and Stress Scale-21 Items
      11. Clinically Useful Depression Outcome Scale
      12. Frequency, Intensity, and Burden of Side Effects Rating
      13. The Columbia Suicide Severity Rating Scale
    5. Treatment Approaches
      1. Cognitive-Based Therapy
      2. Interpersonal Psychotherapy
      3. Behavior Therapy
      4. Brief Dynamic Therapy
      5. Mindfulness-Based Cognitive Therapy
      6. Problem-Solving Therapy and Solution-Focused Brief Therapy
      7. Marital and Family Therapy
      8. Emotion-Focused Therapy
      9. Emotional Freedom Techniques
      10. Psychoeducation
      11. Mobile Apps
      12. Other Therapeutic Options 
    6. Cultural Considerations
    7. Advocacy
    8. Conclusion
    9. Resources
    10. References

Practice Briefs

Major Depressive Disorder

Contributors: Carlos P. Zalaquett, SeriaShia Chatters, and Saiber Shaikh

Abstract: Major depressive disorder (MDD), also known as clinical depression, is a prevalent mental health disorder affecting approximately 21 million adults and 5 million adolescents in the United States annually (Brody & Hughes, 2025). It’s a leading cause of disability worldwide, impairing daily life, exacerbating medical conditions, and increasing suicide risk (World Health Organization [WHO], 2025). MMD is diagnosed through clinical interview and mental status examination, client’s self-reported symptoms, observations from relatives or close contacts, and findings from assessment instruments.

Introduction

Major depressive disorder (MDD), also known as clinical depression, is a prevalent mental health disorder affecting approximately 21 million adults and 5 million adolescents in the United States annually (Brody & Hughes, 2025). It’s a leading cause of disability worldwide, impairing daily life, exacerbating medical conditions, and increasing suicide risk (World Health Organization [WHO], 2025). MMD is diagnosed through clinical interview and mental status examination, client’s self-reported symptoms, observations from relatives or close contacts, and findings from assessment instruments. No laboratory test can confirm the disorder, but referral to medical evaluation could exclude physical illnesses with similar symptoms, like diabetes, thyroid disorders, or Parkinson’s disease.

Description of Major Depressive Disorder

MDD is a mood disorder characterized by one or more major depressive episodes without any history of episodes of mood elevation and increased energy (mania or hypomania; WHO, 2025, 2005). Diagnosis of a major depressive episode requires at least five of these symptoms: depressed mood most of the day nearly every day, as indicated by either subjective report; markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day; significant weight loss when not dieting or weight gain; insomnia or hypersomnia nearly every day; psychomotor agitation or retardation nearly every day; fatigue or loss of energy nearly every day; feelings of worthlessness or excessive or inappropriate guilt; diminished ability to think or concentrate, or indecisiveness, nearly every day; and recurrent thoughts of death. Symptoms must be present for the same two-week period (i.e., they cannot occur in one week, pause for weeks at a time, and then occur in a later week) and must include a change from previous functioning, lasting at least two weeks (American Psychiatric Association [APA], 2022).

Diagnosis of MDD requires a severity specifier (mild, moderate, or severe) based on number of symptoms and personal and social functional impairment, ensuring the symptoms are not better explained by normal bereavement, substance use, medical condition, or another disorder. Eight additional specifiers are include anxious distress; mixed features; melancholic features; atypical features; psychotic features; catatonia; peripartum onset; and seasonal pattern (APA, 2022). Each symptom requires severity indication.

Differential Diagnosis

MDD is distinguished from other depressive disorders by duration, timing, and etiology. Persistent depressive disorder involves a chronic depressed mood lasting at least two years (one year in youth) versus MDD’s episodic presentation (minimum two weeks), whereas premenstrual dysphoric disorder is temporally linked to the menstrual cycle. MDD is frequently over-diagnosed due to failure to distinguish it from normal sadness and grief, which typically involve feelings of emptiness and loss that decrease in intensity over days to weeks and occur in waves tied to reminders of loss. In contrast, MDD involves a persistent depressed mood and pervasive unhappiness with diminished positive affect across contexts (APA, 2022).

Neurobiological research indicates MDD reflects disruptions across affective, cognitive, and neurovegetative systems, with multifactorial etiologies spanning genetic, inflammatory, environmental, and psychosocial domains (Bains & Abdijadid, 2023; WHO, 2025).  

Prevalence

MDD affects about 21 million U.S. adults a year (8.3%). Prevalence is higher among adult women (10.3%) than adult men (6.2%). It affects 20.1% of youth between ages 12 and 17 and is nearly times times more among girls (29.2%) than boys (11.5%; National Institute of Mental Health [NIMH], 2023). Prevalence is higher in younger adults (18–24) than older adults (≥65), higher in non-Hispanic White than other racial and ethnic groups, and higher in adults with less than a high school education than those with a high school education or a college degree (Brody & Hughes, 2025).

Earlier age of onset is associated with a more severe clinical course over the lifespan, including increased likelihood of recurrence, longer episode duration, greater functional impairment, and higher rates of comorbid conditions. Globally, individuals experiencing MDD onset in adolescence or early adulthood may face cumulative effects on educational attainment, career development, and relationship formation during critical developmental periods (Khademi et al., 2025; Jamet et al., 2024).

MDD remains among one of the most significant contributors to health loss worldwide (Global Burden of Disease Collaborative Network, 2025) and is the leading cause of disability in the United States for ages 15–44 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023).

Many professionals, including primary-care physicians and mental-health clinicians, have difficulties diagnosing depression (Zierer et al., 2024). Use of accepted assessments, routine mental health checks, and culturally sensitive interviewing is recommended (Bradford et al., 2024; Fekadu et al., 2022; Grung et al., 2024; Habtamu et al., 2023). Current emerging approaches such as two-step machine-learning model (Eder et al., 2025) and use of passive data (e.g., smartphone use, sleep, activity monitoring, communication patterns) are developed to reduce misdiagnosis.

Assessment Strategies

The assessment strategies presented in this section include interview and self-report measures that may be used to screen, diagnose, or track treatment outcomes. Each strategy has been demonstrated to be valid and reliable. The following are important factors to consider when selecting an appropriate assessment.

  • Purpose: Screening, diagnosing, or monitoring treatment.
  • Population: Age, cultural background, and comorbidities.
  • Validity and reliability: Use assessments with strong psychometric properties.
  • Practicality: Consider time, ease of administration, and scoring.
  • Clinical suggestions: Use screening and diagnostic tools routinely to diagnose and monitor depression; use patient-rated instruments to save time; and use evidence-informed treatments and collaborative care to manage MDD effectively.

Center for Epidemiologic Studies Depression Scale

The Center for Epidemiologic Studies Depression scale (CES-D; Radloff, 1977) is a 20-item scale developed to measure symptoms of depression in community populations. The CES-D has four separate factors: (a) depressive affect, (b) somatic symptoms, (c) positive affect, and (d) interpersonal relations.

Patient Health Questionnaire

The nine-item Patient Health Questionnaire (PHQ-9) is a self-report depression assessment tool, derived from the interview-based Primary Care Evaluation of Mental Disorders (PRIME-MD; Spitzer et al., 1999). Completion takes about five minutes, and it is useful for the diagnosis of major depression in primary care (Richardson et al., 2010; Phelan et al., 2010). The two-item Patient Health Questionnaire (PHQ-2) includes two items from the PHQ-9 and evaluates its presence during the last two weeks (Gilbody et al., 2007; Keenan et al., 2023).

The Hospital Anxiety and Depression Scale

The Hospital Anxiety and Depression Scale (HADS) is a 14-question self-rating scale that measures anxiety and depression in both hospital and community settings (Zigmond & Snaith, 1983). The one-page scale can be completed in a couple minutes (Bjelland et al., 2002; Pignatiello et al., 2021).

Zung Self-Rating Depression Scale

The Zung Self-Rating Depression Scale (Zung SDS) is a 20-item self-report screening questionnaire, covering affective, psychological and somatic symptoms of depression (Zung, 1965). Completion takes about 10 minutes (Thurber et al., 2002). Monitors change over time and can be used with older adults (Jokelainen et al., 2019).

Beck Depression Inventory

The Beck Depression Inventory (BDI-II) is a 21-item self-report inventory measuring the severity of depression, but is not a diagnostic tool (Beck et al., 1996). Completion takes about 10 minutes. Versions exist for other countries (Tung et al., 2023).

Hamilton Depression Rating Scale

The Hamilton Depression Rating Scale (HDRS) has 17 original items; new versions include as many as 29 (Hamilton, 1960). Completion takes 20 minutes. Questions 18–21 can give further information such as diurnal variation or paranoid symptoms.

Quick Inventory of Depressive Symptomatology

The Quick Inventory of Depressive Symptomatology (QIDS) is a 16-item instrument that can be used to assess depression based on the International Classification of Diseases, 11th Revision (ICD-11) diagnostic criteria (Rush et al., 2003; Haley et al., 2023; Robinson & McAllister-Williams, 2024).

Montgomery-Åsberg Depression Rating Scale

The Montgomery-Åsberg Depression Rating Scale (MADRS) is a 10-item instrument used to assess clients’ mood, feelings of unease, sleep, appetite, ability to concentrate, initiative, emotional involvement, pessimism, and zest for life (Montgomery & Åsberg, 1979). Completion takes 20 minutes. There is a version for adolescents (Vestin et el., 2024).

PROMIS Emotional Distress—Depression—Short Form

PROMIS-SF is an eight-item self-report questionnaire for adults assessing depression severity over the past seven days. It measures negative mood, negative views of self, and decreased positive affect (Cella et al., 2019).

Depression, Anxiety, and Stress Scale-21 Items

Depression, Anxiety, and Stress Scale-21 Items (DASS-21) is a 21-item self-report questionnaire designed to measure the severity of emotional distress through three subscales: depression, anxiety, and stress (seven items each). It distinguishes depression (hopelessness, low self-esteem) from anxiety (autonomic arousal, panic) and stress (tension, irritability) over the past week (Lovibond & Lovibond, 1995).

Clinically Useful Depression Outcome Scale

The Clinically Useful Depression Outcome Scale (CUDOS) is useful to identify remission and assess psychosocial impairment, and quality of life (Zimmerman et al., 2008).

Frequency, Intensity, and Burden of Side Effects Rating

The Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) scale is useful to monitor side effects of treatment and interference with functioning. Counselors need to ask about specific concerns (Wisniewski et al., 2006).

The Columbia Suicide Severity Rating Scale

Suicide and suicidal thoughts and behaviors in clients taking antidepressant medications are worldwide concerns. The Columbia Suicide Severity Rating Scale (C-SSRS) is useful to monitor suicidality (Daray et al., 2025).

Treatment Approaches

The following therapies are supported by randomized control trials and other evidence; can be used with individuals and groups, online, or self-help format; are effective with clients of different ages, and backgrounds; and effects are similar or better than pharmacotherapy (Cuijpers et al., 2024; Veterans Affairs and Department of Defense, 2022; Sampson, 2023).

Select treatment using a collaborative process that balances scientific evidence with client-centered factors. Consider evidence, client preferences, symptom complexity, therapist training, prior treatment history, practical constraints, and the potential for a strong therapeutic alliance. Effectiveness of treatment increases when the client understands it, believes in it, and participates in it. Evaluate treatment on an ongoing basis and make adjustments or changes as needed.

Cognitive-Based Therapy

Cognitive behavior therapy (CBT) is a time-limited, collaborative therapy. The goals of CBT are to change thoughts, improve skills, and modify emotional states that contribute to mental disorders. It can be applied using techniques from Beck’s (1967) cognitive therapy; Ellis’s rational emotive behavioral therapy (REBT) model (Ellis, 1973; Ellis & Grieger, 1986); Meichenbaum’s (1977) cognitive behavioral modification; and others (Cuijpers et al., 2023; Fordham et al., 2021; Zalaquett & Stens, 2006; Zalaquett et al., 2019).

Interpersonal Psychotherapy

Interpersonal psychotherapy (IPT) for depression focuses on interpersonal roles and conflicts (Kennedy & Tanenbaum, 2000). It addresses grief, interpersonal disputes, role transitions, and interpersonal deficits. Short-term IPT involves 20 hourlong sessions once a week (Bian et al., 2023; Cuijpers et al., 2024; Zalaquett & Stens, 2006).

Behavior Therapy

Behavioral interventions include contextual approaches based on functional analyses (e.g., contingency management, behavioral activation), social skills training, self-control therapy, problem-solving therapy, and behavioral marital therapy. Therapeutic strategies include self-monitoring, self-reinforcement, graded task assignments, activity scheduling, and social skills through assertiveness training, modeling, role-playing, and relaxation training (Zalaquett et al., 2019; Zalaquett & Stens, 2006).

Brief Dynamic Therapy

Brief dynamic therapy (BDT) explores unconscious processes and processes lifetime developmental issues to facilitate client insight and changes. Its goals are to increase insight into unconscious processes and to institute corrective experiences through interaction with therapists. Transference and countertransference are important (Leichsenring et al., 2023).

Mindfulness-Based Cognitive Therapy

Mindfulness-based cognitive therapy (MBCT) combines elements of CBT with mindfulness-based stress reduction. Eight weeks of MBCT treatment reduces symptoms and relapses (Karrouri et al., 2021).

Problem-Solving Therapy and Solution-Focused Brief Therapy

Problem-solving therapy (PST) and solution-focused brief therapy focus on negative assessments of situations and solving strategies (Karrouri et al., 2021; Rhodes, 2023).

Marital and Family Therapy

Marital and family problems can make people more vulnerable to depression, and marital and family therapy (MFT) addresses these issues. Therapy includes couples or family counseling, as depression occurs in these interpersonal contexts, to facilitate communication and resolution of issues (Karrouri et al., 2021).

Emotion-Focused Therapy

Emotion-focused therapy (EFT) is a short-term (8–20 sessions) structured therapeutic approach to working with individuals, couples, and families. It is based on attachment theory, but includes elements of other theories (Koren et al., 2022).

Emotional Freedom Techniques

Emotional freedom techniques (EFT) is a self-help approach that combines elements of acupressure, CBT, and mindfulness. It involves tapping specific points on the body to release emotional blockages and promote relaxation.

Psychoeducation

This type of intervention educates depressed patients and, with patient permission, family members about depression symptoms and management. It addresses misperceptions about treatment duration and risk of relapse. It improves clinical course, treatment adherence, and psychosocial functioning (Karrouri et al., 2021).

Mobile Apps

Research on mental health apps (MHAs) shows a positive impact of mobile apps on depression symptoms across age groups and populations (Araib et al., 2025; Bae et al., 2023; Firth et al., 2017; Torous et al., 2020).

Other Therapeutic Options 

For each of the following recommend client see a psychiatrist or their primary care physician for evaluation and prescription: Antidepressant medication, repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), electroconvulsive therapy (ECT), and physical exercise might be appropriate for clients with MDD (Aparicio et al., 2026; Stenmark et al., 2021; Zhao et al., 2025).

Cultural Considerations

There is substantial cross-cultural variation in the prevalence, course, and symptomatology of depression (APA, 2022). These differences underscore the need for culturally humble assessment and culturally responsive treatment approaches. Countries use context-specific clinical guidelines that emphasize cultural humility, addressing power imbalances, and advocating for clients and focus on equity, access, and empowerment through self-awareness, understanding diverse worldviews, advocacy, and proactive action. The Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016) offers a comprehensive framework for counselors to navigate the intersections of personal bias, institutional barriers, and client-centered, culturally relevant healing.

Advocacy

Effective advocacy for MDD involves actions to improve awareness, reduce stigma, expand access to quality care, promote culturally informed education, promote research, center the voices of people who have experienced depression, and influence policies and clinical practice, as demonstrated by the Depression and Bipolar Support Alliance and the National Alliance on Mental Illness.

Conclusion

This Practice Brief reviews the complexities of MDD conceptualizations, diagnosis, and treatment, highlighting substantial cultural differences in prevalence and symptom expression. It advocates for structured and evidence-based diagnostic practices, emphasizes the importance of culturally responsive care, and discusses assessments to improve accuracy. It also outlines key domains for advocacy, including public awareness, access to care, policy influence, and the empowerment of those with lived experience, all aimed at enhancing the quality and reach of depression care in the United States.

Resources

  • Depression, American Counseling Association
  • Rapid Response by A. T. Burtka, Counseling Today
  • Treating Depression by Focusing on Solutions and Acceptance by L. R. Rhodes, Counseling Today
  • Seasonal Affective Disorder and the Summertime Blues by S. Cooper, Counseling Today
  • Support Resources for Anxiety, Depression, and Related Disorders, Anxiety & Depression Association of America
  • Mental Health Resource for Your Clients/Patients, Anxiety & Depression Association of America
  • 2026 ICD-10-PCS Official Guidelines for Coding and Reporting, Centers for Medicare and Medicaid Service
  • Everything You Need to Know About Depression (Major Depressive Disorder), Healthline
  • Resource List, Mental Health America
  • Depression in Black Americans, Mental Health America
  • Depression in Teens, Mental Health America
  • Major Depression, National Institute of Mental Health
  • Resource Links, National Network of Depression Centers
  • Depression in Adults, UK National Institute for Health and Care Excellence
  • Depression in Children and Young People, UK National Institute for Health and Care Excellence
  • Depression and Anxiety, UK National Institute for Health and Care Excellence
  • International Statistical Classification of Diseases and Related Health Problems (ICD), World Health Organization
  • Depression, National Center for Health Statistics
  • Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts, APA
  • DSM-5-TR Online Assessment Measures
  • The Center for Epidemiologic Studies Depression Scale Revised (CESD-R)
  • Patient Health Questionnaire (PHQ) Screeners
  • Hospital Anxiety and Depression Scale (HADS)
  • Zung Self-Rating Depression Scale (SDS)
  • Beck’s Depression Inventory (BDI-II)
  • Hamilton Depression Rating Scale (HDRS)
  • Inventory of Depressive Symptomatology (IDS) and Quick Inventory of Depressive Symptomatology (QIDS)
  • Montgomery-Asberg Depression Rating Scale (MADRS)
  • Patient-Reported Outcomes Measurement Information System (PROMIS)
  • Depression Anxiety Stress Scales (DASS)

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To Cite This Practice Brief:

Zalaquett, C. P., Chatters, S., & Shaikh, S. (2026, March). Major depressive disorder [Practice Brief]. Counseling Nexus. https://doi.org/10.63134/OJVF2304

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